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HX641 17693 
RC206  .  B69  Yellow  fever  and  its 


VRT    I 


FEVER 


,f  JD  ITS   PREVENTION 


SIR  ROBERT  BOYCE.ERS. 


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Reference  Htbrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

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YELLOW    FEVER 

AND    ITS    PREVENTION 

A  MANUAL  FOR  MEDICAL  STUDENTS 
AND  PRACTITIONERS 

BY  SIR  RUBERT  W.    BOYCE,    M.B.,  F.R.S. 

HOLT  PROFESSOR    OF    PATHOLOGY,   UNIVERSITY    OF    LIVERPOOL  ;     DEAN  OF  THE 

LIVERPOOL  SCHOOL  OF    TROPICAL    MEDICINE  ;     COMMANDER  OF  THE  ORDER  OF 

LEOPOLD  III.  ;    FELLOW    OF    UNIVERSITY    COLLEGE,    LONDON  ;      BACTERIOLOGIST 

AND   ONE   OF   THE   PUBLIC   ANALYSTS   TO    THE    CITY    OF    LIVERPOOL 


WITH  ILLUSTRATIONS 


NEW    YORK 
E.    P.    DUTTON    AND    COMPANY 

1911 


is] 


TO   THE  LATE 

SIR  ALFRED  LEWIS  JONES,  K.C.M.G. 

FOUNDER  AND  GENEROUS  BENEFACTOR  OF  THE 
LIVERPOOL  SCHOOL  OF  TROPICAL   MEDICINE 

WHOSE  INTENSE  SYMPATHY    WITH  THE    SUFFERING  OF    HIS    FELLOW 

MEN,    VIVID     IMAGINATION,     AND     GREAT     GRASP      OF      AFFAIRS, 

STIMULATED    THE    AUTHOR    TO    TRAVEL    AND    TO     ACQUIRE 

KNOWLEDGE     IN     DISTANT      PARTS      OF     THE     TROPICAL 

WORLD,   THIS  VOLUME  IS  DEDICATED 

IN 

AFFECTIONATE  AND  GRATEFUL  REMEMBRANCE. 


PREFACE 

ALTHOUGH  I  cannot  say,  like  the  illustrious  historian x  of  the 
plague  at  Athens,  "having  myself  had  the  distemper,"  I  can 
repeat  with  him  "  having  seen  others  suffering  under  it,  I  will 
state  what  it  actually  was,  and  will  indicate,  in  addition,  such 
other  matters  as  will  furnish  any  man  who  lays  them  to  heart, 
with  the  knowledge  and  the  means  of  calculating  before- 
hand, in  case  the  same  misfortune  should  ever  again  occur." 
This  work  is,  in  fact,  a  summary  of  my  experiences  and  investiga- 
tions in  New  Orleans  early  in  1905,  in  British  Honduras  and 
Central  America  late  in  1905,  in  Barbados  and  other  islands  of  the 
West  Indies,  and  British  Guiana  in  1909;  and  lastly,  in  Sierra 
Leone,  the  Gold  Coast,  Southern  Nigeria,  in  West  Africa  in  1910, 
to  all  of  which  places  I  was  sent  out  to  investigate  the  subject 
of  yellow  fever.  I  have  treated  the  subject-matter  historically, 
geographically,  and  from  the  point  of  view  of  symptomatology  and 
treatment,  pathology,  diagnosis,  epidemiology,  entomology,  and 
prophylaxis,  and  I  hope  that  the  manual  will  be  of  practical 
value  to  the  young  medical  student  who  intends  taking  up 
work  in  the  tropics.  Having  already  in  my  book  on  Health 
Progress  and  Administration  in  the  West  Indies  sketched  the 
history  of  yellow  fever  and  its  prevention  in  the  West  Indies 
and  in  Central  America,  I  have  in  the  following  pages  laid 
special  stress  upon  the  question  of  yellow  fever  in  West  Africa, 
believing  that  if  the  existence  of  the  disease  is  fully  recognised, 

1  Thucydides,  ii.,  48. 


viii  PREFACE 

and  the  simple  measures  which   I   advocate  are  followed,  the 

conquest  of  West  Africa  will  be  free  from  the  ghastly  set-backs 

which  the  pioneers  of  Central  and  South  America  and  the  West 

Indies  experienced  during  the  many  years  in  which  they  were 

engaged  building  up  commerce  and  civilisation. 

RUBERT   BOYCE. 

The  University,  Liverpool, 
December  1910. 


ACKNOWLEDGMENTS 

In  my  previous  works  on  yellow  fever  I  have  acknowledged  my 
indebtedness  to  the  numerous  medical  officers  and  administrators 
who  so  liberally  assisted  my  investigations  in  the  past. 

In  the  present  volume,  which  embodies  my  experiences  in 
West  Africa,  I  desire  to  especially  thank  Drs  Rice,  Kennan, 
Strachan,  Graham,  Garland,  and  Pickels,  and  their  assistants, 
all  of  them  colleagues  with  whom  I  worked  in  the  19 10  outbreak. 
For  great  hospitality  and  advice  I  especially  desire  to  record 
my  thanks  on  the  Gold  Coast  to  the  late  Sir  John  Rodger, 
K.C.M.G.,  and  Mr  Furley,  D.C ;  in  Nigeria  to  Mr  Thorburn, 
C.M.G.,  and  Mr  James  ;  in  Sierra  Leone  to  Sir  Leslie  Probyn, 
K.C.M.G. 

I  also  desire  to  express  my  indebtedness  to  my  colleagues 
Mr  Robert  Newstead,  M.Sc,  and  Professor  Howard  Kelly  of 
Baltimore,  for  advice  and  assistance  in  the  preparation  of  this 
work.  For  the  reproductions  44,  46,  47,  51,  and  52,  I  am 
indebted  to  Dr  White  of  New  Orleans;  for  charts  6,  and  13  to 
16  to  the  work  of  Dr  Guiteras  of  Havanna,  and  to  Faget's  work 
for  the  reproduction  of  several  very  interesting  temperature  and 
pulse  curves. 

I  desire  also  to  thank  Colonel  Sutton,  R.A.M.C,  and  the 
Colonial  Office  for  valuable  assistance  rendered  in  enabling  me 
to  consult  original  reports. 


CONTENTS 


PART  I 


HISTORY   AND    GEOGRAPHICAL    DISTRIBUTION   OF   YELLOW 

FEVER 


I.  History  of  Yellow  Fever  in  Central  America 

II.  History  of  Yellow  Fever  in  South  America 

III.  History  of  Yellow  Fever  in  the  West  Indies 

IV.  History  of  Yellow  Fever  in  North  America 
V.  History  of  Yellow  Fever  in  Europe 

VI.  History  of  Yellow  Fever  on  Ships 

VII.  History  of  Yellow  Fever  on  the  West  Coast  of  Africa 


PAGE 

3 

9 

14 

25 
33 
42 
48 


PART  II 


SYMPTOMATOLOGY  AND  TREATMENT 


VIII.     Experimental  Yellow  Fever  and  Yellow  Fever  Types  .        99 

IX.     The  Clinical  History  of  Various  Epidemics  of  Yellow  Fever       127 

X.     The  Symptoms  of  some  of  the  Cases  of  Yellow  Fever  which 

have  appeared  in  West  Africa  in  recent  years  .       165 

XI.     Diagnosis  .......       197 

XII.     Treatment  .  .  .  .  .  .  .208 


xii  CONTENTS 

PART     III 

PATHOLOGY 

CHAP.  PAGE 

XIII.  Experimental  Pathology  .  .  .  .  .219 

XIV.  Morbid  Anatomy  and  Histology  .  .  .  .227 

PART  IV 

EPIDEMIOLOGY 

XV.     Epidemiology    .......       237 

XVI.     Race  Susceptibility  and  Immunity      ....       252 

PART  V 

ENTOMOLOGY 

XVII.     Geographical  Distribution  of  the  Stegomyia  calopus  .       265 

XVIII.     Distribution  of  the  Stegomyia  in  Africa  .  .  .       287 

PART  VI 

PROPHYLAXIS 


XIX.  Plan  of  Campaign         ..... 

XX.  Early  Notification  and  Notification  Fear 

XXI.  Anti-mosquito  Ordinances        .... 

XXII.  Town   Planning  and   Segregation— Mining  and   Railway 
Works     ...... 

XXIII.  Yellow  Fever  Prophylaxis  in  West  Africa,  1906  and  1910 

XXIV.  Quarantine  Administration      .... 


303 

316 
325 

334 
34o 
355 


Index       .........      371 


LIST  OF  ILLUSTRATIONS 


FIG.  TO   FACE  PAGE 

i.  A  Well-kept  Native  Village  with  Pipe-borne  Water  Supply  Frontispiece 
i.  Yellow  Fever  Chart   .  .  .  .  .  .  .2 

3.  A  Concreted  Water  Course,  Trinidad  ....         14 

4.  A  Concrete  Roadside  Drain,  Trinidad         .  .  .  .18 

5.  Large  Rain- Water  Cisterns,  New  Orleans  .  .  .  .         26 
I.  Map  Showing  Distribution  of  Yellow  Fever            .            .            .48 

6.  Temperature  and  Pulse  Curves,  Experimental  Yellow  Fever         .       100 

7.  Average  Temperature  Curves  in  Yellow  Fever        .  .  .126 

8.  Average  Pulse  Curves  in  Yellow  Fever        .  .  .  .126 

9.  Average  Temperature  and   Pulse  Curves   in    Non-fatal   Yellow 

Fever       .  .  .  .  .  .  .  .128 

10.  Average  Temperature  and  Pulse  Curves  in  Fatal  Yellow  Fever  128 

1 1.  Average   Temperature  and  Pulse   Curves  in   Non-fatal  Yellow 

Fever      ........       130 

12.  Average  Temperature  and  Pulse  Curves  in  Fatal  Yellow  Fever    .       130 

13.  Average  Temperature  and  Pulse  Curves  in  Descending  Type  of 

Yellow  Fever      .  .  .  .  .  .  .132 

14.  Average  Temperature  and  Pulse  Curves  in  Continuous  Type  of 

Yellow  Fever      .  .  .  ,  .  .  .132 

15.  Average  Temperature  and  Pulse  Curves  in  Remitting  Type  of 


Yellow  Fever 


134 


16.  Average  Temperature  and  Pulse  Curves  in  Fatal  Case  of  Remit- 
ting Type  .......       134 


XUl 


xiv  LIST  OF  ILLUSTRATIONS 

FIG.  TO   FACE    PAGE 

17.  Temperature  and   Pulse  Curves  in  a  Case  of  Yellow   Fever  in 

Barbados  .... 

18.  Mosquito  Screened  Ambulance 

19.  Mosquito  Proof  Room 

20.  Section  of  Kidney,  Yellow  Fever  (low  power) 

21.  Section  of  Kidney,  Yellow  Fever  (low  power) 

22.  Section  of  Kidney,  Yellow  Fever  (high  power) 

23.  Section  of  Kidney,  Yellow  Fever  (high  power) 

24.  Section  of  Kidney,  Yellow  Fever  (high  power) 

25.  Section  of  Kidney,  Yellow  Fever  (high  power) 

26.  Section  of  Kidney,  Showing  Congestion  of  Vessels 

27.  Section  of  Kidney,  Showing  Early  Fatty  Degeneration 

28.  Section  of  Liver,  Showing  Advanced  Fatty  Degeneration 

29.  Section  of  Liver,  Showing  Destruction  of  Liver  Cells 

30.  Plan   of  Barbados,    Showing   Progress  of  Epidemic  of  Yellow 

Fever      ..... 

31.  Spot  Map  of  New  Orleans,  Showing  Distribution  of  Yellow  Fever 

32.  Curve  of  Yellow  Fever  Epidemic,  New  Orleans,  1905 

33.  Showing  Yellow  Fever  Death  Rate  in  Rio,  1890- 1905 

34.  Diagram  Showing  Proportion  of  Yellow  Fever  Cases,  in  Whites 

and  Blacks,  in  Outbreaks  in  West  Africa 

35.  Map  Showing  Distribution  of  Stegomyia  fasciata    . 

36.  A  Yard  Showing  Breeding-places  of  Stegomyia 

37.  Figure  Showing  Up-turned  Bottles  Harbouring  Stegomyia 

38.  A  Tree  with  Epiphytes  which  Harbour  Stegomyia 

39.  Larvas  of  Stegomyia  fasciata  .... 

40.  Adult  Stegomyia  fasciata       .  .  .  . 

41.  Figure  Showing  Characters  of  Larvas  of  Stegomyia 
II.  Map  Showing  Distribution  of  Stegomyia  in  West  Africa    . 

42.  Dust  Cart  Brigade,  for  Removal  of  Odds  and  Ends  Liable   to 

Harbour  Stegomyia 

43.  An  Anti- Stegomyia  Brigade  . 


LIST  OF  ILLUSTRATIONS 


xv 


FIG. 

44.  Heaps  of  Odd  Water  Receptacles  Collected  from  Yards 

45.  Destroying  Mosquitos  in  Sheds  by  Means  of  Steam 

46.  A  Carefully  Screened  Water  Cistern 

47.  An  Oiling  and  Screening  Gang 

48.  Screening  Water  Cisterns 

49.  Filling  in  Swamp  by  Hand  Labour  . 

50.  Filling  in  Swamp  by  Sand  Pump 

51.  House  Surrounded  by  too  much  Bush 

52.  Papering  Houses 

53.  Papering  Outhouses  . 

54.  Killing  Mosquitos  in  Houses  by  the  Clayton  Sulphur  Apparatu 

55.  Clayton  Apparatus  at  Work  . 

56.  Well-planned  Coolie  Ranges 

57.  Well-planned  Road  with  Table  Drains 

58.  A  "Bee  Hive"  Refuse  Destructor    . 

59.  Fumigating  Gang,  Secondee 

60.  Rain  Water  Vat,  Secondee   . 

61.  Refuse  Destructor,  Coomassie 


TO    FACE    PAGE 
298 


302 

3°4 
306 
306 
308 
308 
310 
312 
312 
3H 
314 
334 
336 
34o 
342 
344 
346 


PART     I 

HISTOEY  AND   GEOGRAPHICAL 
DISTRIBUTION   OF  YELLOW  FEVER 


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CHAPTER   I 

HISTORY   OF   YELLOW   FEVER   IN    CENTRAL  AMERICA 

The  fragmentary  historical  evidence  which  we  possess,  tends 
to  show  that  yellow  fever  existed  amongst  the  native  races 
of  Central  America  when  the  Spaniards  arrived. 

It  is  stated  to  have  been  known  to  the  ancient  Mexicans. 
It  was  found  in  Columbian  times  amongst  the  peoples  inhabit- 
ing the  New  World.  Centuries  afterwards  evidence  points  to 
a  similar  endemic  foothold  on  the  West  Coast  of  Africa. 

But,  although  it  is  not  fruitful  to  speculate  where  a  disease 
like  yellow  fever  or  malaria,  both  intimately  bound  up  with 
the  progress  of  the  human  race,  first  made  their  appearance, 
nevertheless  useful  practical  information  is  gained  by  reviewing 
the  historical  data  in  connection  with  the  progress  of  both 
diseases.  The  information  so  gained  is  of  use  from  the 
epidemiological  standpoint,  for  it  shows  clearly  how  disease 
follows  closely  upon  the  expansion  of  civilisation,  whether 
the  lines  along  which  it  travels  be  religious,  military,  or 
commercial. 

For  example,  it  is  to  the  monks  who  accompanied  the 
Spanish  and  Portuguese  races  in  their  numerous  expeditions 
to  the  New  World  in  the  Middle  Ages  that  we  owe  the  little 
we  possess  to-day  of  the  "  discovery,"  or  rather  chronicling  of 
the  sudden  outbursts  of  the  new  and  mysterious  disease  which 
so  seriously  impeded  the  founding  of  settlements  in  the 
New  World. 


4  YELLOW  FEVER  IN  CENTRAL  AMERICA 

Chief  References  for  General  History  and  Distribution 
of  Yellow  Fever 

Hirsch  (August)—  Handbook  of  Geographical  Pathology ',  New  Sydenham 

Society,  vol.  cvi.,  London,  1883. 
Augustin  (G.) — History  of  Yellow  Fever,  New  Orleans,  1909. 
The  1852  Commission,  Whitehall,  Lo7idon,  "Yellow  Fever." 
CLEMOW  (F.  G.) — The  Geography  of  Disease,  Cambridge,  1903. 
The  Public  Health  and  Marine  Hospital  Service  Reports,  Washington 

(published  monthly). 
Boyce  (Sir  R.   W.) — Health  Progress  and  Administration  in  the   West 

Indies,  London,  1909. 
BERENGER-FERAUD  (L.  J.  B.) — Traite  de  la  fievre  jaune,  Paris,  1890. 
Humboldt  (A.) — Essai politique  sur  le  royaume  de  la  nouvelle  Espagne. 
Sternberg  (W.) —  Handbook  of  the  Medical  Sciences. 
Le  BOEUF  (Dr) — "History  of  Yellow  Fever,"  New  Orleans  Medical  and 

Surgical  Journal,  1905. 

History  of  Yellow  Fever  in  Central  America 
{From  Sixteenth  to  Twentieth  Centuries) 

Yellow  fever  is  stated  to  have  been  known  in  pre-Columbian 
times,  and  that  it  was  called  "  Matlazahuatl "  by  the  ancient 
Mexicans.  It  is  also  said  to  have  been  present  in  Vera  Cruz 
since  1509.  In  other  words,  yellow  fever  was  one  of  the 
established  indigenous  diseases  when  the  early  explorers 
arrived  from  Europe.  After  the  sixteenth  and  seventeenth 
centuries  there  appears  to  have  been  a  pause,  and  it  is  not 
until  the  nineteenth  century  that  yellow  fever  becomes  again 
prominent,  owing  no  doubt  to  commercial  expansion  in  the 
eighteenth  and  nineteenth  centuries. 

In  Mexico,  as  stated  above,  yellow  fever  appears  to  have 
been  known^to  the  ancient  Mexicans;  and  at  Vera  Cruz,  the 
large  port  in  the  Gulf  of  Mexico,  the  disease  is  said  to  have 
been  endemic  since  1509.  The  reason  why  our  knowledge  of 
yellow  fever  in  Mexico  goes  back  further  than  in  other 
American  republics,  is  no  doubt  due  to  the  fact  that  the  country 
was  the  seat  of  an  old  civilisation,  and  that  it  early  attracted 
adventurers.  When  in  later  ages  other  ports  and  towns  were 
opened  to  Europeans  and  North  American  commerce,  yellow 


MEXICO  5 

fever  immediately  made  its  appearance  in  epidemic  form.  In 
fact,  yellow  fever  followed  closely  the  trade  routes,  whether  by 
road,  rail,  or  sea,  and  whether  along  the  coast,  in  the  interior 
wilder  districts,  or  up  on  to  the  mountains. 

Wherever  newcomers  settled,  the  disease  broke  out,  in 
some  cases  no  doubt  from  an  imported  source,  but  as  often  as 
not  from  the  endemic  source.  Vera  Cruz,  being  the  great  port, 
has  persisted  as  a  centre  of  yellow  fever  to  modern  times,  the 
disease  manifesting  itself  in  larger  or  smaller  epidemics,  or  as 
annual  sporadic  cases  depending  upon  the  number  of  non- 
immunes present  in  any  one  year,'  and  therefore  influenced  by 
the  movements  of  troops  or  settlers. 

In  like  manner,  the  ports  of  Tampico  and  Progresso  have 
been,  since  the  early  part  of  the  nineteenth  century,  the  seats 
of  epidemics  and  sporadic  cases.  Large  epidemics  have  been 
recorded  at  Tampico  in  1843  and  in  1847.  Merida,  the  capital 
of  Yucatan,  is  still  an  endemic  focus.  In  Mexico  city,  built 
at  an  elevation  of  7450  feet,  only  imported  cases  of  yellow 
fever  have,  it  is  stated,  occurred. 

Vigorous  anti-yellow  fever  operations  have  been  undertaken 
in  the  chief  towns  of  Mexico,  notably  at  Vera  Cruz. 

References  For  Yellow  Fever  in  Mexico 

Liceaga  (E.) — "Yellow  Fever  in  Mexico,"  American  Health  Association 

Annual  Convention,  1893. 
Boyce  (Sir  R.  W.) — Report  upon  Outbreak  of   Yellow  Fever  in  British 

Honduras  in  1905,  London,  1906. 
LlCEAGA  (E.) — "Yellow  Fever  in  Mexico,"  Transactions  of  the  XV.  Inter- 
national Medical  Congress,  Lisbon,  1906. 
Augustin  (G.) — History  of  Yellow  Fever,  New  Orleans,  1909. 
Parker,  Beyer,  and  Pothier — Report  of  the    Working  Party  No.  Z, 

Yellow  Fever  Institute,  Washington,  1903. 
Bolletim  extraordinario  del  Consejo  superior  de  Salubridad  Mexico. 
Manuel  Carmona  y   Valle,  Lecons  sur  Vetiologie  et  la  prophylaxie  de  la 

fievre  jaune,  Mexico,  1885. 
Seidelin  (H.)— "Aetiologie  des  Gelben  Fieber,"  Berliner  Klin.  Wochen., 

No.  18,  1909  ;  "Experiences  in  Yucatan,"  Yellow  Fever:  Journal  of 

Trop.  Med.,  November  1910. 


6     YELLOW  FEVER  IN  CENTRAL  AMERICA 

In  British  Honduras  yellow  fever  was  no  doubt  endemic  in 
the  early  part  of  the  seventeenth  century  at  the  time  of  its 
settlement  in  1630. 

Analysis  of  the  Surgeon-General's  returns  show  that  in  1886 
there  were  17  cases;  in  1887,  16  cases;  probably  some  cases 
in  1889;  in  1890,  19  cases;  in  1891,  3  cases;  in  1905, 
40  to  50  cases. 

Since  1905  no  primary  cases  have  been  recorded  in  Belize. 
After  that  year  anti-mosquito  regulations  were  adopted. 

References  for  Yellow  Fever  in  British  Honduras 

Boyce  (Sir  R.  W.) — Report  to  the  Government  of  British  Honduras  upon 
the  Outbreak  of  Yellow  Fever  in  1905,  London,  1906. 

LAWSON  (R.) — "  Yellow  Fever,"  Transactions  of  the  Epidemiological  Society, 
London,  i860,  vol.  iii.  ;  also  Brit,  and  Foreign  Med.  Chir.  Review, 
1862. 

In  Guatemala  yellow  fever  is  still  probably  endemic.  At 
Livingston,  a  fruit  port  on  the  Atlantic  side,  a  yellow  fever 
epidemic  was  recorded  in  1891  ;  another  in  1905  ;  no  doubt, 
however,  sporadic  cases  have  occurred  in  intermediate  years. 
In  1905  severe  epidemics  occurred  in  the  interior  towns  as 
Zacapa  and  Gualan,  and  isolated  cases  at  Puerto-Barrios,  and 
other  small  towns.  The  1905  outbreaks  were  probably  due  to 
the  opening  up  of  the  country  by  railroads,  and  in  conse- 
quence of  the  increase  of  non-indigenous  non-immunes.  It 
is  noteworthy  that  the  disease  went  under  the  name  "  railway 
fever."     At  Zacapa,  700  cases  were  reported  in  1905. 

References  for  Yellow  Fever  in  Guatemala 

Boyce  (Sir  R.  W.) — Report  to  the  Government  upon  the  Outbreak  of  Yellow 

Fever  in  British  Honduras,  1905,  London,  1906. 
Reports  of  the  Public  Health  and  Marine  Hospital  Service,  Washington. 

In  Spanish  Honduras  epidemics  are  recorded  in  the  early 
part  of  the  nineteenth  century  (Berenger-Feraud),  1803,  and 
later  in  1850.     But  there  can  be  little  doubt  that  yellow  fever 


HONDURAS  AND  COSTA  RICA  7 

has  been  endemic  from  Columbian  times  (1502)  to  the  present 
period.  In  1905  commercial  and  railway  extension  took  place 
and  at  the  principal  port,  Puerto  Cortes,  yellow  fever  broke  out 
in  1905,  when  50  deaths  were  recorded.  The  new  arrivals  were 
the  first  to  succumb.  From  the  seaport  the  disease  is  supposed 
to  have  spread  to  the  interior  ;  one  town — San  Pedro — reported 
621  cases. 

References  for  Yellow  Fever  in  Spanish  Honduras 

Boyce    (Sir  R.   W.) — British    Honduras,   loc.  cit.j    Washington    Health 

Reports^  loc.  cit. 
Berenger-F£raud    (L.  J.  B.) — Traite  theorique  et  pratique  de  la  fievre 

jaune,  Paris,  1890. 

In  Nicaragua  yellow  fever  commences  to  be  recognised  about 
the  middle  of  the  nineteenth  century.  Cases  have  been  recorded 
at  Bluefields,  a  small  fruit  port  on  the  coast.  Yellow  fever 
was  present  in  the  interior  in  1905.  The  disease  is  no 
doubt  endemic. 

References  for  Yellow  Fever  in  Nicaragua 

Boyce  (Sir  R.  W.)—Loc.  cit. 
Berenger-Feraud  (L.  J.  B.) — Loc.  cit. 
Lawson  (R.)— Loc.  cit. 

In  Costa  Rica — the  chief  seaport  is  Port  Limon — yellow  fever 
appears  to  have  only  commenced  to  attract  attention  since 
1890,  that  is,  since  commercial  expansion  took  place.  Yellow 
fever  is  probably  endemic.  Outbreaks  are  recorded  in  1901 
and  1903,  also  numerous  small  outbreaks  up  to  date  (1910). 

References  for  Yellow  Fever  in  Costa  Rica 

Washington  Health  Reports,  loc.  cit. 
AUGUSTIN  (G.)— Loc.  cit. 

In  Salvador. — This  republic  is  on  the  Pacific  side  of  Central 
America,  and  therefore  more  excluded  from  the  lines  of  traffic 
common  to  the  Atlantic  side.. 


8  YELLOW  FEVER  IN  CENTRAL  AMERICA 

Yellow  fever  commences  to  be  recorded  about  the  middle 
of  the  nineteenth  century,  401  cases  being  recorded  in  San 
Salvador  in  1868.  Small  outbreaks  and  sporadic  cases  are  of 
very  frequent  occurrence. 

References  for  Yellow  Fever  in  Salvador 
C ORN I LLI  AC — Recherche s  chronologiques. 
Guzman — These,  Paris,  1869. 

Panama,  was  no  doubt  until  recent  years  an  endemic 
centre  of  yellow  fever.  The  construction  of  the  Isthmian  Canal, 
and  the  giving  over  to  the  Isthmian  Canal  Commission  of  the 
Isthmian  Canal  Zone,  as  well  as  the  placing  of  other  towns  in 
the  vicinity  under  modern  sanitary  supervision,  has  effected  the 
complete  disappearance  of  endemic  yellow  fever.  As  showing 
the  immense  strides  in  yellow  fever  preventive  measures,  it  is 
worthy  of  note  that  the  French  in  the  first  year  of  their  attempt 
to  construct  a  canal  had  a  death-rate  of  60S  per  thousand,  the 
American  Commission  a  death-rate  of  15-8  per  thousand 
employees.  Since  1905  there  have  been  no  cases  of  yellow 
fever. 

References  for  Yellow  Fever  in  Panama 
Public  Health  Reports,  loc.  cit. 
BOYCE  (Sir  R.  W.) — Health  Progress,  loc.  cit. 

"Isthmian  Canal  Commission,  1908,"  Annual  Report.     Dept.  of  Sanitation. 
"Isthmian  Canal  Commission,  1906,"  Bulletin  No.   2.     Laboratory  of  the 

Board  of  Health. 
"Isthmian    Canal    Commission,"    Reports   of  Health    Officer,    1905-1907 

(Georgas,  W.  G.). 
Carter  (R.  H.) — "Notes  on  the  Sanitation  of  Yellow  Fever  and  Malaria, 

from     Isthmian     Experience,"    Medical    Record,   vol.    lxxvi.,    July 

1909. 


CHAPTER   II 

HISTORY   OF   YELLOW   FEVER   IN   SOUTH   AMERICA 

(From  Eighteenth  to  Twentieth  Century,  chiefly  Nineteenth 

Century) 

In  Venezuela  yellow  fever  is  still  endemic,  and  has  preserved 
in  all  probability  an  unbroken  record  from  pre-Columbian 
times;  numerous  epidemics  are  recorded  in  the  seventeenth, 
eighteenth,  and  nineteenth  centuries.  There  was  an  epidemic 
at  Ciudad  Bolivar  in  1907,  and  in  the  same  year  the  disease  is 
stated  to  have  been  continually  present  in  La  Guayra  and  in 
Caracas.     Cases  are  also  recorded  in  19 10. 

In  January  19 10,  the  President  of  Venezuela  created  a 
Department  of  Hygiene  in  the  Administration,  to  be  under  the 
immediate  charge  of  a  director,  who  should  also  act  as  secretary 
of  the  Superior  Council  of  Hygiene  and  Public  Health.  Already 
the  department  has  issued  a  memorandum  to  the  public  dealing 
with  yellow  fever  prevention. 

References  for  Yellow  Fever  in  Venezuela 

Boyce  (Sir  R.  W.)— Health  Progress,  loc.  cit. 

HlRSCH  (A.) — Geographical  and  Historical  Pathology,  loc.  cit. 

E-EAUPERTHUY     (L.      D.)  —  Travanx     scientifiqiies    de     Louis     Daniel 

Beauperthuy,   Docteur  en    medecine   des  Facultes    de    Paris  et   de 

Cardcas,  Bordeaux,  1891. 
"  Outbreak  of  Yellow  Fever  in  Venezuela,"  Boston  Medical  and  Surgical 

Journal,  Oct.  19 10. 

hi  British  Guiana. — Yellow  fever  was  also  no  doubt  endemic 
when   it  was  first  settled  in  the  early  part  of  the  seventeenth 

century.     It  is  not,  however,  until  later  in  the  eighteenth  and 

9 


10  YELLOW  FEVER  IN  SOUTH  AMERICA 

in  the  nineteenth  century  that  yearly  regular  records  of  out- 
breaks amongst  sailors  and  new  arrivals  generally  are  recorded. 
In  1840  the  mortality  from  yellow  fever  was  such  that  in  a 
few  months  69  per  cent,  of  all  the  white  troops  had  perished. 
After  this  period  there  is  a  lull  and  outbreaks  are  not  again 
recorded  until  1881  and  1888,  and  since  the  last  date  no  cases 
appear  to  have  been  chronicled.  This  improvement  dates  back 
to  the  sixties,  when  sanitary  reform,  just  as  in  other  countries, 
began  to  gradually  banish  the  endemic  type  of  the  disease. 

References  for  Yellow  Fever  in  British  Guiana 
Blair   (N.) — Some  Account  of  the    Yellow   Fever  Epidemic  of  British 

Guiana,  London,  1858. 
British  Guiana  Medical  Annual,  1896. 
Report  of  the  Commission  upon  the  General  and  Infantile  Mortality,  British 

Guiana,  1906. 
BOYCE   (Sir  R.    W.) — Health   Progress  and  Administration  in   the   West 

Indies,  London,  1909. 

In  French  Guiana  evidence  exists  that  the  fever  which 
impeded  the  progress  of  the  gold  mining  enterprises  of  1871 
was  yellow  fever.  This  disease  is  in  every  probability  endemic. 
Numerous  epidemics  are  recorded  in  the  eighteenth  century 
and  also  during  the  nineteenth  century. 

References  for  Yellow  Fever  in  French  Guiana 
COTHOLENDY    (F.)  —  Qicelques    considerations    sur    les    ende'mies    de    la 

Guyanne,  These,  Paris,  1857. 
ESQUERRA  (Carlos) — Contribution   a,  V etude  de   la  fievre  de  Magdalena, 

Paris,  1899 
Esquerra  (Domingo) — Memorie  sobre  les  fiebres  Magdalena,  Magdalena, 

1872. 
Garnier  (A.) — "  La  fievre  jaune  a  la  Guyanne  avant  1902,  et  l'epidemie  de 

1902,"  Annates  d 'hygiene  et  de  Med.  Col.,  Paris,  1904. 
Jacquier  (P.  V.) — Essai  sur  Phygiene  de  la   Guyanne  francaise,  These, 

Paris,  1835. 
Dorvau  (F.  H.) — Considerations  sur  Phygiene  et  la  pathologie  des  cher- 

cheurs  dor  a.  la  Guyanne  franqaise,  These,  Montpellier,  1876. 
Gomez  (Proto) — "  Los  mosquitos  y  la  fiebre  amarilla,"  Revista  medica  de 

Bogota,  No.  15,  1887. 

In  Dutch  Guiana  the  history  of  yellow  fever  is  similar  to 
that  of  the  two  preceding  colonies :  epidemics  were  common  and 


GUIANA  AND  BRAZIL 


11 


attracted  attention  from  the  end  of  the  eighteenth  century  to 
the  nineteenth  century,  and  15  cases  were  described  in 
1908  to  1909. 

References  for  Yellow  Fever  in  Dutch  Guiana 
Hirsch  (A.) — Loc.  cit. 
Boyce  (Sir  R.  W.) — Health  Progress  in  the  West  Indies,  loc.  cit. 

In  Brazil  when  commercial  development  set  in  yellow  fever 
came  into  prominence ;  thus  in  1850,4000  deaths  from  yellow 
fever  were  reported  in  Rio. 

Numerous  epidemics  are  also  recorded  in  the  sixties  and 
seventies,  and  in  the  year  1894,  5000  died  in  Rio  from  that 
disease  alone. 

The  following  table  shows  the  annual  and  monthly  deaths 
from  yellow  fever  in  Rio  from  1896  to  the  present  time.  The 
table  also  shows  how  as  the  result  of  anti-mosquito  measures, 
taken  in  the  year  1903,  the  disease  has  been  stamped  out,  and 
is  now  no  longer  endemic  : — 

Deaths  from  Yellow  Fever  in  Rio  de  Janeiro  since  1896. 


Year. 

January. 

February. 

March. 

April. 

May. 

June 

1896 

690 

986 

1433 

557 

171 

34 

1897 

38 

65 

88 

66 

36 

16 

1898 

19 

Il6 

310 

278 

178 

82 

1899 

138 

235 

258 

IOI 

40 

22 

1900 

57 

49 

89 

5o 

21 

13 

1901 

24 

55 

83 

66 

38 

22 

1902 

48 

86 

223 

218 

2o8 

128 

1903 

184 

219 

270 

148 

44 

20 

1904 

5 

7 

9 

8 

10 

4 

Year. 

July. 

August. 

September. 

October. 

November. 

December. 

1896 

24 

16 

4 

19 

12 

28 

1897 

5 

2 

I 

4 

4 

1898 

54 

3D 

14 

12 

17 

30 

1899 

17 

7 

14 

II 

19 

35 

1900 

7 

6 

3 

7 

7 

5 

I90I 

19 

5 

15 

16 

9 

10 

1902 

85 

54 

38 

39 

36 

121 

1903 

16 

12 

4 

4 

3 

4 

1904 

4 

1 

2 

... 

3o 

12  YELLOW  FEVER  IN  SOUTH  AMERICA 

References 

Fernandez  (S.    G.) — A  profilaxia  da  febre  amarela  no   Para,"  Revista 

Propagador  da  fnedicina  natural  e  Beneficente,  August  1910. 
Otto  u.  Neumann — "  Studien  iiber  Gelbfieber  in  Brasilien,"  Zeitschr.  f. 

infects.  Krankh.,  1905. 
Pedro  Torres  Caleira — Mangrove  Tree  Destruction  and  Yellow  Fever, 

Rio,  1884. 
GOUY  (E.) — Histoire  de  lafievrejaune  au  Brazil,  Paris,  1884. 
RlBAS   (E.) — Instructions  sanitaires  tendant  a  eviter  la  Propagation  de  la 

fievre  jaune,  S.  Paulo,  Brazil,  1903. 
Barreto,    Barros,    and   Rodrigues — Rapport  des  experiences  faites  a 

Phopital  disolement  de  St  Paul,  1903. 
Durham  (H.  E.),  Myers  (Walter) — Notes  on  Sanitary  Conditions  obtaining 

in  Para.     Yellow   Fever   Expedition.     Liverpool,    1901  ;   Report  of 

Yellow  Fever  Expedition  to  Para,  1900.     Memoir  VII.,  Liverpool 

School  of  Tropical  Medicine. 
THOMAS   (H.  W.) — La  sanidad publica  de  Iquitos,  1905  ;  "Report  of  the 

1905-1909  Expedition  to  the  Amazon,"  Annals  of  Tropical  Medicine, 

vol.  iv.,  Liverpool  School  of  Tropical  Medicine. 
Publications  of  the  Instituto  Oswaldo  Cruz,  Rio  de  Janeiro,  1909. 
Bartarelli    (E.)  —  "Die   Bekampfung    des   gelben   Fiebers    in    Rio    de 

Janeiro,"  Wien.  Klin.  Rundschau,  1906,  vol.  xx.,  pp.  897-99. 
Strain  (W.  Loudon) — Yellow  Fever;  its  Mode  of  Discrimination,  S.Paulo 

Epidemic,  1 892  - 1 893. 

During  the  period  of  trade  expansion,  the  disease  spread 
from  the  older  established  and  larger  centres  of  commerce  to 
every  new  settlement,  either  along  the  coast  or  into  the  interior. 
Yellow  fever  also  appeared  for  the  first  time  in  surrounding 
republics,  where  before  it  had  been  overlooked  or  had  not 
appeared ;  as  fast,  in  fact,  as  these  countries  unfolded  to 
commerce. 

Whilst  yellow  fever  has  ceased  to  be  endemic  in  Rio,  it  still 
retains  its  endemic  character  at  various  trade  centres  along  the 
Amazon ;  but  here  also  steps  have  recently  been  taken  to  get 
rid  of  it. 

There  is  no  doubt  that  both  malaria  and  yellow  fever  have 
existed  endemic  side  by  side,  especially  in  the  towns  along  the 
river  Magdalena.  "  Magdalena  fever  "  is  only  another  place  name 
of  yellow  fever.     Epidemics  have  been  recorded  in  1830,  1837, 


ENDEMIC  CENTRES  13 

1860-1S65,  1870-1871,  and  1884.  Along  the  rivers  Magdalena, 
Orinoco,  and  Amazon,  yellow  fever  has  been  from  the  earliest 
times  endemic,  and  to-day  they  remain  strongholds. 

From  the  preceding  statements,  it  is  clear  that  places  exist 
in  Central  and  South  America  where  yellow  fever  is  still  endemic, 
much  as  it  was  when  the  Spanish  Conquistadores  landed.  It 
will  also  be  noticed  that  yellow  fever  does  not  again  commence 
to  be  chronicled  until  the  period  when  military  operations,  gold 
mining,  industrial  developments,  railway  and  canal  construction 
and  steam-ship  routes  open  up  anew  these  countries. 

From  this  period  through  the  nineteenth  century,  there  is  a 
second  great  recrudescence  of  yellow  fever,  lit  up  from  the  old 
slumbering  endemic  foci,  as  well  as  imported  afresh  from  other 
centres.  This  present  century,  in  striking  contrast,  is  marked 
by  the  curtailment  or  disappearance  of  yellow  fever  in  con- 
sequence of  anti-mosquito  measures. 

It  will  also  have  been  noted  that  yellow  fever  did  not  remain 
confined  to  the  endemic  foci  in  Brazil,  the  Guianas,  Colombia, 
Ecuador,  and  Venezuela  in  the  nineteenth  century.  It  also 
spread  to  other  commercial  centres  in  South  America,  where 
there  is  no  evidence  that  the  disease  was  naturally  endemic. 
For  example,  epidemics  are  recorded  in  Peru  in  1842,  1852, 
1854,  1869.  Cases  were  recorded  at  Callao  in  1889.  Similar 
outbreaks  took  place  in  the  seventies  in  Monte  Video  and  Buenos 
Ayres  and  Ascension. 

References 

Hirsch    (A.) — Handbook    of  Geographical    and    Historical    Pathology, 

London,  1883. 
Clemow  (F.  G.) — The  Geography  of  Disease,  Cambridge,  1903. 
Sodr£   (A.   A.   A.)   and   Couto    (M.)  —  Das  Gelbfieber,   Spec.   Path,  and 

Therap.  Nothnagel,  Wien,  1901,  Bd.  V. 


CHAPTER   III 

HISTORY   OF   YELLOW   FEVER   IN    THE   WEST   INDIES 

We  can,  I  think,  come  to  no  other  conclusion  than  that  yellow 
fever  was  endemic  in  these  islands  at  the  time  of  their  invasion 
by  the  Latin  races  in  the  sixteenth  and  seventeenth  centuries. 
The  regularity  with  which  yellow  fever  broke  out  amongst  the 
white  newcomers  in  their  settlements  is  proof  of  this. 

In  1493  an  epidemic  is  recorded  at  Isabella  in  St  Domingo 
about  the  time  of  its  foundation  by  Columbus. 

In  1508  one  in  Porto  Rico, 

In  1620  to  1648  in  Cuba, 


In  1635 
In  1648 
In  1649 
In  1649 
In  1655 
In  1665 


in  Guadeloupe, 

in  St  Kitts, 

in  Martinique, 

in  Barbados, 

in  Jamaica, 

in  St  Lucia. 

After  the  seventeenth  century,  or  the  age  of  Latin  military 
and  missionary  enterprise,  yellow  fever  receded  in  prominence, 
until  British  military  and  commercial  activity  set  in  with  the 
rise  of  British  naval  supremacy,  then  once  more  yellow  fever 
comes  into  prominence.  In  the  eighteenth,  and  earlier  part  of 
the  nineteenth  century,  it  constitutes  the  fever  of  the  principal 
towns  of  the  Islands,  the  West  Indian  "endemial"  or  "acclima- 
tising" fever,  which  every  newcomer  was  certain  to  get  soon 
after  his  arrival.  It  attacked,  in  regular  epidemic  form,  the 
troops  which  from  time  to  time  were  sent  out  from  England ; 


■5^ 


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<u    O 


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& 

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T3 

0) 

IU 

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CQ 

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T3 

PAST  AND  PRESENT  HISTORY  15 

because  the  arrival,  in  an  endemic  centre  of  yellow  fever,  of  from 
one  to  three  hundred  troops  was  sufficient  to  light  up  an 
epidemic  in  almost  any  year,  the  medical  military  records  of  the 
Windward  and  Leeward  commands  are  of  the  greatest  interest 
to  the  student  from  this  standpoint.  They  show  that  yellow 
fever  appeared  in  an  unbroken  line  from  1815  to  1846  in  the 
island  of  Barbados  and  at  intervals  to  1846.  Similar  records 
exist  for  the  islands  possessed  by  other  nations. 

A  West  Indian  military  report  of  the  time  states  :  "  The 
arrival  of  a  stranger  at  almost  any  time  or  season  in  the  West 
Indies  was  sufficient  to  develop  yellow  fever."  From  these  well- 
authenticated  records  we  must  conclude  that  yellow  fever 
persisted  in  its  endemic  form  amongst  the  regular  inhabitants 
of  the  towns,  be  they  whites,  Creoles,  or  blacks,  until  compara- 
tively modern  times. 

In  the  modern  period,  the  growth  of  hygiene  bringing  in 
with  it  cleaner  yards  and  streets,  and  above  all  a  pipe-borne 
water  supply,  did  away  with  the  old-time  wells,  barrels,  and 
innumerable  receptacles  employed  to  store  the  rain,  river,  or 
well  water.  This  reform  (commencing  about  1850)  struck  at 
the  root  of  endemic  yellow  fever.  It  reduced  the  breeding- 
places  of  the  Stegomyia  to  that  point  at  which  yellow  fever 
ceases  to  be  endemic. 

From  about  the  year  1850,  however,  small  outbreaks  of 
yellow  fever  occurred  from  time  to  time,  not  from  the  presence 
of  an  endemial  disease  but  as  the  result  of  imported  cases,  or 
imported  infected  Stegomyia  from  distant,  centres  where  the 
disease  was  still  endemic,  viz.,  Venezuela  and  the  Amazon. 
The  imported  infection  caused  an  outbreak  limited  in  extent 
solely  by  the  local  supply  of  Stegomyia  and  the  number  of  non- 
immune inhabitants.  These  points  were  clearly  brought  out  by 
investigations  which  I  conducted  in  1909  in  the  British  West 
Indies,  and  by  those  which  a  French  Commission  conducted 
at  the  same  time  in  Martinique  and  Guadeloupe. 

In  the  case  of  Barbados,  the  fever  attacked  the  coloured  and 


16  YELLOW  FEVER  IN  THE  WEST  INDIES 

black  population  with  more  frequency  than  the  white.  This,  I 
concluded,  showed  that  endemial  yellow  fever  had  long  ceased  to 
exist,  and  that  in  consequence  the  majority  of  the  dwellers  in 
the  island  were  non-immunes ;  it  also  showed  that  there  was  a 
sufficient  supply  of  Stegomyia  to  give  rise  to  numerous  cases, 
provided  that  infection  were  imported  from  without.  Investiga- 
tion showed  that  this  in  every  probability  did  actually  occur  in 
a  crowded,  poor  district  in  Bridgetown,  the  principal  town  of  the 
Island.  In  this  particular  quarter  it  was  shown  that  the 
Stegomyia  was  breeding  in  abundance,  and  might  have  readily 
been  infected  from  some  mild  or  unrecognised  case  of  yellow 
fever  arriving  from  the  Amazon,  or  other  centre  where  there 
was  yellow  fever,  and  within  the  time  limit  of  the  incubation  of 
the  disease. 

In  the  case  of  the  other  West  Indian  islands  in  which  a  few 
cases  of  yellow  fever  were  recorded,  the  evidence  likewise  was 
all  in  favour  of  importation.  In  the  case  of  the  French  islands, 
Martinique  and  Guadeloupe,  the  Commission  inclined  to  the 
belief  that  the  outbreaks  in  those  islands  were  not  due  to 
imported  yellow  fever  but  to  endemial  yellow  fever.  This 
endemial  fever  was  of  such  a  mild  type  that  it  went  under  the 
name  of  "  inflammatory  fever,"  in  consequence  its  true  nature 
was  not  appreciated.  From  this  mild  form  of  yellow  fever  the 
mosquito  became  fully  infected,  and  was  able  to  communicate  it 
in  its  virulent  form  to  new  arrivals,  or  to  returning  residents 
who  had  resided  some  time  out  of  the  colony.  In  support  of 
their  contention  they  showed  that  the  islands  since  1649  had 
been  continually  the  seat  of  outbreaks  of  the  disease  down  to  the 
year  1895,  and  they  contended  that  in  the  intervals  in  all 
probability,  mild,  unrecognised  cases  of  yellow  fever  occurred, 
and  that  these  kept  up  continuous  infection  in  the  Stegomyia. 
If  we  may  assume  the  preceding  reasoning  to  be  correct,  it 
shows  how  in  the  West  Indies  yellow  fever  was  endemic  to 
commence  with,  i.e.,  about  1493,  how  it  long  continued  to  remain 
so,  and   how   the  magnitude  and   frequency  of  the  epidemics 


ENDEMIC  CENTRES  17 

increased  coincident  with  military  and  commercial  expeditions 
and  the  growth  of  towns,  until  altered  hygienic  conditions 
commencing  about  the  years  1850  to  i860  had  in  many  of  the 
islands  brought  about  the  cessation  of  the  continuous  connected 
outbreaks  of  yellow  fever  ;  had  in  other  words  stopped  the  flow 
of  endemial  yellow  fever.  These  sanitary  changes  had  not, 
however,  brought  about  the  complete  destruction  of  the 
Stegomyia.  In  consequence  we  find  localised  and  limited  out- 
breaks of  yellow  fever  down  to  the  year  1909,  due,  in  the 
majority  of  instances,  to  importation  of  infection  from  without. 

In  the  case,  however,  of  the  Martinique  and  Guadeloupe 
epidemic,  the  recrudescence  appears  to  have  been  due  to  the 
persistence  in  all  probability  of  the  original  endemial  yellow 
fever  common  to  all  the  islands  in  the  fifteenth  and  sixteenth 
centuries. 

References  to  Yellow  Fever  in  the  West  Indies 
ROCHEFORT — Histoire  naturelle  et  morale  des  Isles  Antilles  de  VAme'rique, 

1558. 
HlRSCH     (A.)  —  Handbook    of   Geographical    and   Historical   Pathology, 

London,  1883. 
Sternberg  (G.)— In  Janus. 

Clemow  (F.  G.) — The  Geography  of  Disease,  Cambridge,  1903. 
Boyce  (Sir  R.  W.) — Health  Progress  and  Administration  in  the  West  Indies, 

2nd  edition,  London,  1910. 
Pym  (Sir  William) — Observations  upon  Bulam,   Vomito  Negro  or  Yellow 

Fever,  London,  1848. 
Lawson  (Robert) — "Observations    upon    Yellow    Fever,"    British    and 

Foreign  Med.   Chi.  Review,  1862;   Second  Report  on   Quarantine, 

Yellow  Fever,   London,  1852  ;    Essai  sur  le  climat  et  les  maladies 

des  Antilles,  Dissertation  G.  J.  A.  C.  de  St  Cyr,  Montpellier,  1826. 
I zett- Anderson — Yellow  Fever  in  the  West  Indies,  London,  1898. 
Dutroulau — Topographie   me'dicale    des    climats    intertropicaux,    Paris, 

1858. 
"  Moreau  de  Jonnes  des   effets  du  climat  des   Antilles,"  Bulletins  de  la 
faculte  de  medecine  de  Paris,  Paris,   18 16  ;  "  Morreau  de  Jonnes," 

Tableau  du  climat  des  Antilles,  Paris,  18 17  ;  "Morreau  de  Jonnes," 

Essai  sur  V hygiene  militaire  des  Antilles,  Paris,  1816. 
Cassan   (J.) — "  Memoires   sur  le  climat   des   Antilles,"     Me'moires  de  la 

socie'te  medicate  d emulation,  1 803. 

B 


18  YELLOW  FEVER  IN  THE  WEST  INDIES 

KERAUDREN    (P.    F.) — De  la  fievre  jaujte  observee  aux  Antilles  et  sur 

les   Vaissaux  du  roi  consider  de  principalement  sous  le  rapport  de  sa 

transmission,  Paris,  1823. 
NICOLAS  (A.) — Une page  de  climatologie  intertropicale,  Paris,  1887. 
LAVACHER  (M.  G.) — Guide  medical  des  Antilles,  Paris,  1834. 
Blair   (N.) — Some  Account  of  the    Yellow  Fever   Epidemic  of  British 

Guiana,  London,  1850. 
Dixon  (Nodes) — Observations  on  the  Inflammatory,  Endemic,  or  Yellow 

Fever  in  the  West  Indies,  London,  18 19. 
Wilson  (T  G.) — "  Observations  on  the  Yellow  Fever  Epidemic  at  Bermuda," 

1864,  Lancet,  1872. 

The  following  are  the  chief  historical  data  connected  with 
yellow  fever  in  the  principal  West  Indian  islands : — 

Grenada. — Yellow  fever  is  said  to  have  been  introduced  in 
1793  from  West  Africa,  and  in  consequence  was  called  "  Bulam 
fever."  It  certainly  could  have  readily  been  introduced  ;  but  in 
all  probability  the  fever  was  naturally  endemic  to  this  as  to 
other  islands  of  the  group.  In  181 8  the  mortality  amongst  the 
troops  is  given  as  21  per  cent.  The  last  cases,  probably  endemic 
ones,  were  recorded  in  1881. 

References 

BOYCE  (Sir  R.  W.)—Loc.  cit. 
Annual  Medical  Reports  of  Grenada. 

St  Vincent. — Yellow  fever  is  recorded  regularly  in  the 
nineteenth  century  until  1822  ;  it  then  fell  back.  In  1909  five 
cases  were  recorded,  due,  it  is  stated,  to  an  imported  case. 

References 

The  Second  Report  on  Quarantine,  Yellow  Fever,  London,  1852. 

BOYCE  (Sir  R.  W.)—Loc.  cit. 

Annual  Medical  Reports  of  St  Vincent. 

St  Lucia. — In  the  year  1796,  800  troops  perished  of  yellow 
fever  in  the  year.  It  v/as  very  prevalent  in  the  nineteenth 
century.     In  1827  the  mortality  amongst  the  troops  was  stated 


FlG.  4. — A  Concrete  Roadside  Drain,  Port  of  Spain,  Trinidad. 


[To  face  p.  IS. 


TRINIDAD  19 

to  be  21  per  cent.     No  cases  have  been  recorded  in  recent 

years. 

References 

The  Second  Report  on  Quarantine,  1852,  "Dr  A.  Browne  on  West  Indian 

Fever." 
BOYCE  (Sir  R.  W.)—Loc.  at. 
Hodder  (Major) — The  Destruction  of  Mosquitos  in  St  Lucia,  1902- 1903  ; 

Annual  Medical  Reports. 
Levacher  (M.  G.) — Guides  des  Antilles,  Paris,  1834. 

Trinidad  and  Tobago. — Yellow  fever  was  very  prevalent  in 
the  nineteenth  century  up  to  1818,  when  the  mortality  reached 
30  per  cent,  in  both  islands.  In  1821  it  was  25  per  cent.  After 
this  period  no  doubt  isolated  cases  continued  to  occur.  Thus  in 
1907  there  were  50  cases;  in  1908  150  cases;  in  1909  1  case 
is  reported.  Yellow  fever  is,  however,  not  now  endemic,  but 
Trinidad  is  very  close  to  and  in  constant  communication  with 
Venezuela,  which  is  an  endemic  focus. 

References 
The  Second  Report  on  Quaratitine,  Yellow  Fever,  London,  1852. 
BOYCE  (Sir  R.  W.)—Loc.  cit. 
Annual  Medical  Reports  of  Trinidad. 
Tulloch  (J.  P.) — Journal  of  Tropical  Medicine,  December  1910. 

St  Kills  or  Christopher. — In  the  seventeenth  and  eighteenth 
centuries  outbreaks  are  recorded. 

References 
Blair  (N.) — Loc.  cit. 
BOYCE  (Sir  R.  W.)—Loc.  cit. 
Second  Report  on  Quarantine,  1852,  "Dr  A.  Browne  on  West  Indies." 

Antigua  and Monserrat. — Yellow  fever  is  recorded  from  18 17- 
1836.  In  the  1816  epidemic  in  Antigua  it  was  noticed  that  no 
natives  were  attacked,  which  is  proof  that  the  disease  was 
endemic. 

REFERENCES 
Second  Report  07i  Quarantine,  1852. 
Boyce  (Sir  R.  W.)—Loc.  cit. 


20  YELLOW  FEVER  IN  THE  WEST  INDIES 

MUSGRAVE  (A.) — "  History  of  the  Progress  and  Inquiry  into  the  Causes  of 
the  Yellow  Fever  as  it  appeared  in  the  island  of  Antigua  in  the  year 
1816"  (communicated  by  Dr  Fergusson),  Med.  Chi.  Trans.,  London, 
1818. 

Furlinge  (G.)— "Report  on  Certain  Cases  of  Yellow  Fever,  St  John's, 
Antigua,"  Lancet,  1850. 

In  Dominica  the  death-rate  in  18 17  was  29  per  cent,  amongst 
the  troops. 

In  Tortola,  Nevis,  and  the  Bahamas  yellow  fever  occurred 
regularly  in  the  nineteenth  century. 

References 
Second  Report  on  Quarantine. 
Blair  (N.) — Loc.  cit. 
BOYCE  (Sir  R.  W.)—Loc.  cit. 

Jamaica. — In  1780,  3500  deaths  are  recorded  in  a  period  of 
four  years.  From  18 17- 1847  the  mortality  was  very  high 
amongst  the  white  troops,  but  almost  nil  amongst  the  black. 
After  this  period  the  cases  became  very  much  fewer  up  to  the 
year  1889.  There  was  an  outbreak,  however,  with  38  deaths,  in 
1 897- 1 898. 

In  1899  there  were  some  very  suspicious  cases  diagnosed  as 
remittent  fever.  In  1904  7  cases  with  3  deaths  were  reported, 
and  in  1905  there  was  1  death  from  yellow  fever  in  Kingston. 
The  chief  factors  in  putting  an  end  to  the  endemic  yellow  fever 
which  prevailed  in  the  nineteenth  century  were  a  pipe-borne 
filtered  water  supply,  first  introduced  in  the  year  1897,  and 
increased  attention  to  general  sanitation. 

The  disease  is  now  no  longer  endemic  in  Kingston,  nor 
probably  in  any  part  of  the  island. 

References 

Maunsell(S.  E.) — Contribution  to  the  Medico-Military  History  of  Jamaica, 

1891. 
Jackson  (R.) — A  Treatise  on  the  Fevers  of  Jamaica,  Philadelphia. 
HUNTER  (John) — Diseases  of  the  Army  in  Jamaica,  1788. 
Izett-Anderson — Yellow  Fever  in  the  West  Indies,  London,  1898. 


JAMAICA 


21 


Second  Quarantine  Report,  1852,  uDr  A.  Browne's  Report." 
Boyce  (Sir  R.  \V.)—Loc.  at.,  19 10. 

Annual  Medical  Reports  of  Jamaica,  especially  Reports  of  Dr  Donovan  and 
Dr  Mosse. 


At  Port  Royal  in  Jamaica  there  is  also  evidence  of  an 
unbroken  history  of  yellow  fever  from  the  commencement  of  the 
nineteenth  century  down  to  the  year  1904.  The  record  from 
the  year  1878  is  as  follows  : — 


Year. 

Cases. 

Deaths. 

1878 

16 

II 

1882 

14 

6 

1883 

4 

3 

1885-6 

22 

6 

1890 

8 

I 

1891 

3 

3 

1897 

8 

6 

1900 

1 

1 

1 901 

1 

1 

1902 

1 

1 

1903 

6 

1 

1904 

1 

Some  of  the  above  might  have  been  imported  cases. 

References 

Williams  (John) — Essay  oft  the  Bilious  or    Yellow  Fever  in  Jamaica, 

Kingston,  1750. 
Izett-Anderson — Yellow  Fever  in  the  West  Indies,  London,  1898. 
Second  Report  on  Quarantine,  Yellow  Fever,  London,  1852. 
Blair  (N.) — Some  Account  of  the  Last  Yellow  Fever  Epidemic  of  British 

Guiana,  London,  1850. 
"  Epidemic  of  Malarious  Yellow  Fever  on  Board  the  H.M.S.  Doris  off  Port 

Royal,  1873,"  Lancet,  vol.  i.,  1875. 

Barbados. — Epidemics  are  recorded  in  1647,  and  yellow 
fever  was  known  as  Kendal's  disease  in  1691.  Then  came  the 
usual  pause,  followed  in  the  nineteenth  century  by  a  continuous 
outbreak  coincident  with  military  and  commercial  expansion. 
The  disease  appeared  for  forty  years  in  uninterrupted 
succession. 


22  YELLOW  FEVER  IN  THE  WEST  INDIES 

Yellow  fever  up  to  this  period  was  endemic — about  the 
middle  of  the  nineteenth  century,  when  sanitary  water  reforms 
took  effect  and  epidemics  became  less  in  magnitude  and 
frequency;  one  is  recorded  in  1881.  Since  then  none  are 
recorded  until  1909,  when  the  black  and  coloured  population 
were  more  affected  than  the  white,  showing  that  the  disease 
was  probably  not  endemic  but  imported. 

References 

Second  Report  on  Quarantine,  1852. 

Boyce  (Sir  R.  W.)~Loc.  cit. 

Harrison  (J.  B.),  and  Moxly  (J.  H.  S.) — Reports  upon  Experime?its  con- 
nected with  Yellow  Fever,  Barbados,  1884. 

Blair  (N.) — Some  Account  of  the  Last  Yellow  Fever  Epidemic  of  British 
Guiana,  London,  1850. 

Cuba. — In  1762,  during  the  siege  of  Havana,  8000  soldiers 
and  sailors  were  stricken  with  yellow  fever.  The  disease  was 
known  in  1620  as  the  "pest  of  Havana,"  and  remained  endemic 
there  until  1890,  and  in  other  parts  of  the  island  until  1898. 

In  1900  proof  was  experimentally  furnished  that  the 
Stegomyia  was  the  sole  transmitting  agent  of  yellow  fever — a 
fact  which  in  1881  Finlay  of  Havana  had  also  taught.  In  1909 
there  was  no  yellow  fever  in  Havana,  due  entirely  to  anti- 
Stegomyia  measures.  Yellow  fever  is  in  fact  at  the  present 
time  being  driven  out  of  the  whole  island. 

References 
Chronique  medico-chirugicale  de  la  Havane,  1878. 
Annates  de  la  real  academia  de  ciencia  medica,  Havana,  1S81. 
Annual  Report  of  the  Chief  Sanitary  Officer,  Havana,  1901-1902. 
Diplomatic  and  Consular  Reports,  Cuba,  1907. 
Sanidady  Beneficienza,  Tomo  I.  and  11.,  Havana. 
Selsis  (P.) — Etudes  pour  servir  a  Vhistoire  de  la  fievre  jaune  ou  vomito 

dans  Pile  de  Cuba,  Paris,  1880. 
BELOT  (C.) — La  fievre  jaune  a  la  Havane,  Paris,  1865. 
Public  Health  Reports,  Washington. 
Faundleroy  (P.  C.)— "  Some  Notes  on  the  Last  Epidemics  of  Yellow  Fever 

in  Cuba,"  New  York  Med.  Record,  December  1909. 


MARTINIQUE  23 

Puerto  Rico. — The  seat  of  epidemics  in  the  nineteenth 
century,  since  when  much  has  been  done  to  get  rid  of  endemic 
yellow  fever. 

References 

HlRSCH  (A.) — Handbook  of  Geographical  and  Historical  Pathology. 

Augustin  (G.) — Loc.  cit. 

BOYCE  (Sir  R.  W.) — Loc.  cit.,  1910. 

Martinique  and  Guadeloupe. — These  islands  have  been 
visited  by  repeated  epidemics  during  the  seventeenth, 
eighteenth,  and  nineteenth  centuries,  and  from  a  recent  report 
there  is  reason  to  believe  that  yellow  fever  persisted  in  its 
endemic  form  to  1909,  when  a  considerable  outbreak  occurred 
in  Martinique,  not  as  the  result  of  importation.  It  was 
originally  supposed  that  yellow  fever  was  introduced  into 
Martinique  in  the  year  1649  from  Siam,  hence  the  name 
maladie  de  Siam. 

References 
Second  Report  on  Quarantine,  1852. 

BELOT  (C.) — Fievre  jaune  a  la  Martinique,  Rochefort,  1881. 
MERVILLEUX  (G.) — Considerations  sur  F  hygiene  des  troupes  a  la  Guadeloipe, 

Bordeaux,  1887. 
DUTROULAU — Topographie  medicate  des  climats  iniertropicaux,  Paris,  1858. 
CORNILLAC  (J.) — Etudes  sur  la  fievre  jaune  a  la  Martinique,  1873. 
SlMOND,  Grimand,  Aubert,  ET  NOC — "  Rapport  sur  le  fonctionnement  du 

service   de   destruction  des  moustiques  a   la  Martinique,"   Annates 

d' hygiene  et  de  medecine  coloniale,  1909. 
SlMOND,  AUBERT,  ET  NOC — "Contribution  a  Pepidemiologie  de  la  fievre 

jaune  de  la  Martinique,"  Annates  de  Flnstitut  Pasteur,  1909. 
Launoy   (L.)  —  "Contribution    a    l'etude    de    Pepidemiologie    amarile   de 

Martinique,"  Annates  de  Flnstitut  Pasteur,  Decembre  1909. 

The  Danish  West  Indies. — St  Thomas,  St  Bartholomew's, 
and  St  Martin  have  been  the  seats  of  numerous  outbreaks  in 
the  eighteenth  and  nineteenth  centuries. 

Reference 
Hirsch  (A.)— Loc.  cit. 


U  YELLOW  FEVER  IN  THE  WEST  INDIES 

Hayti  or  Saint  Domingo,  Republic  of  Hayti  and  San 
Domingo. — Epidemics  are  recorded  very  many  times  during  the 
seventeenth,  eighteenth,  and  nineteenth  centuries.  At  the 
present  time  the  disease  is  confined  to  diminishing  areas,  and  is 
not  regarded  as  the  serious  disease  of  the  island. 

References 

La  lanterne  medicate,  Port  au  Prince. 

Gilbert   (G.   N.    P.) — Hisioire    medicate  de   Varmde  francaise    d    Saint 
Domingue  en  Pan  dix,  Paris,  1803. 


CHAPTER  IV 

THE  HISTORY  OF  YELLOW  FEVER  IN    NORTH  AMERICA 

The  history  of  yellow  fever  in  North  America  and  in  Europe 
is  of  great  practical  interest. 

In  the  first  place,  it  will  be  seen  that  the  rise,  progress,  and 
disappearance  of  the  disease  in  these  regions  is  absolutely 
corroborative  proof  of  the  mosquito  doctrine ;  and  in  the 
second  place,  it  shows  how  disease  may  be  carried ;  how  it 
follows  trade  routes  and  commercial  movements,  but  cannot 
establish  itself  permanently  because  certain  conditions  are  not 
fulfilled.  All  these  points  have  a  very  direct  bearing  upon 
the  progress  of  the  disease  to-day.  Admitting  that  the 
primary  endemic  focus  of  yellow  fever  in  the  New  World  is 
Central  and  South  America  and  the  West  Indies,  it  can  be 
readily  understood  how  North  America  was  probably  invaded 
by  the  disease  before  Europe.  The  former,  as  we  shall 
presently  see,  was  comparatively  close  to  the  endemic  centres 
of  infection. 

History  in  North  America 

Yellow  fever  reached  North  America  in  the  middle  of  the 
seventeenth  century — 1668.  That  portion  of  North  America 
which  is  now  the  United  States,  was  then  just  colonised  by 
British,  Spanish,  and  French,  and  was  dotted  over  with 
numerous  small  settlements,  more  especially  along  the  Atlantic 
and  Gulf  coasts,  or  along  the  great  waterways.  The  small 
settlements  established  during  the  last  part  of  the  eighteenth 

25 


26  YELLOW  FEVER  IN  NORTH  AMERICA 

century  and  the  first  half  of  the  nineteenth  century  grew  up 
with  great  rapidity  into  large  commercial  cities  and  ports. 

In  those  days  of  rapid  development  and  comparative 
poverty,  overcrowding  was  the  rule,  and  there  was  little  atten- 
tion paid  to  sanitation  of  any  kind.  The  water  was  obtained 
from  wells  or  roofs,  therefore  cisterns,  barrels,  and  no  doubt  all 
kinds  of  water-containers  were  common.  In  wet  weather 
puddles  formed  everywhere  for  there  was  no  proper  drainage. 
In  other  words,  the  conditions  then  prevalent  were  such  as  are 
now  only  to  be  found  in  some  primitive  West  African  or 
Central  American  coast  town.  These  conditions  would  favour 
no  doubt  the  propagation  of  the  Stegomyia  and  probably 
enabled  it,  by  means  of  the  artificial  warmth  of  the  overcrowded 
houses,  to  survive  through  the  cold  season.  Thus  there  was 
in  those  days  a  continuous  supply  of  Stegomyia,  brought  about 
by  artificial  means. 

Intercourse  between  the  then  British,  French,  and  Spanish 
settlements  in  North  America,  and  the  corresponding  settle- 
ments in  the  West  Indies  and  Central  America  was  constant 
by  means  of  the  old  wooden  ships  of  the  period.  We  know, 
moreover,  that  the  then  proverbial  unhealthiness  of  the  West 
Indies  and  their  perpetual  condition  of  unrest,  produced  by 
frequent  changes  of  government  at  home  and  rebellions  within, 
drove  the  colonists  to  seek  a  safer  and  more  settled  home  in 
North  America,  and  English,  French,  and  Spanish  colonists 
migrated  in  their  hundreds  to  the  more  peaceful  North 
America.  Then  as  soon  as  they  established  themselves,  and 
prosperity  increased,  there  arose  the  demand  for  labour,  and 
the  slave  importation  commenced.  Given,  therefore,  the 
existence  of  the  Stegomyia,  we  can  see  that  they  could  not  long 
remain  uninfected. 

For  convenience,  in  order  to  illustrate  the  progress  of  yellow 
fever  in  North  America,  it  will  be  simpler  to  divide  the  chief 
ports  into  those  placed  on  the  Atlantic  side,  namely : — 
Charleston,   Baltimore,  Philadelphia,  New   York,  and    Boston ; 


THE  GULF  PORTS  27 

and  those  in  the  south,  known  as  the  Gulf  ports,  viz.,  Galveston, 
New  Orleans,  Mobile,  Pensacola,  and  Key  West.  The  climatic 
conditions  of  the  southern  ports  differed  from  those  in  more 
northern  latitudes  ;  the  conditions  were  more  favourable  to  the 
prolonged  propagation  of  the  mosquito  carrier. 

Nevertheless  the  conditions  were  never  so  favourable  as 
those  obtaining  in  the  West  Indies  or  Central  America.  In 
late  autumn  and  in  winter  there  was  a  cold  period  which 
tended  to  put  an  end  to  the  breeding  of  the  Stegomyia. 
Naturally,  the  further  north  the  port  was  situated,  the  more 
effective  did  the  inhibitary  action  of  the  cold  become.  The 
foothold  of  the  Stegomyia  in  North  America  was  in  a  position 
of  unstable  equilibrium  ;  given  a  mild,  frostless  winter  succeed- 
ing the  usually  intensely  hot  summer,  and  the  Stegomyia  could 
survive  to  the  following  year  ;  but  given  a  cold  season  and  the 
Stegomyia  must  have  perished  in  enormous  numbers.  Perhaps, 
however,  not  completely.  For  it  must  not  be  forgotten, 
even  in  countries  where  there  is  a  cold  season,  provided  the 
season  is-  not  too  cold  or  too  prolonged,  that  there  may  exist 
conditions  of  temperature  in  overcrowded  houses  in  the  slums 
of  large  towns,  which  enable  the  Stegomyia  not  only  to  survive 
through  a  winter  but  even  to  propagate,  and  thus  to  keep  up 
the  species  from  one  year  to  another.  But  under  these  condi- 
tions sooner  or  later  the  chances  are  that  a  colder  winter  than 
usual  will  bring  the  species  to  an  end. 

Not  only  in  the  Gulf  ports  like  New  Orleans,  but  also  in 
the  Atlantic  ports  like  New  York,  the  evidence  furnished  by 
the  outbreaks  points  to  the  survival  at  that  period,  not  only  of 
infected  adult  Stegomyia,  but  also  to  the  survival  of  the  species, 
as  we  shall  presently  see.  But  at  all  times,  under  these  condi- 
tions, the  survival  of  the  mosquito  was  exceedingly  doubtful 
and  a  matter  of  accident,  and  this  explains  why  yellow  fever 
could  not  get  a  prolonged  endemic  foothold  in  the  Atlantic 
towns  ;  and  if  by  the  accident  of  favourable  seasons  the  species 
bred  for  many  years  in  succession  in  the  Gulf  towns,  it  was  every 


28  YELLOW  FEVER  IN  NORTH  AMERICA 

severe  cold  season  reduced  enormously  in  numbers,  so  that 
although  there  might  not  be  enough  mosquitos  present  to  keep 
up  the  endemic  character  of  the  disease,  yet  sufficient  existed 
to  give  rise  to  local  outbursts  when  a  case  of  yellow  fever 
was  imported  from  some  locality  where  that  disease  was 
present. 

Galveston  in  Texas. — From  the  year  1839  epidemics  of 
considerable  size  were  common  down  to  the  year  1867.  In  1839, 
when  the  population  of  Galveston  was  only  5000,  the  number  of 
deaths  from  yellow  fever  is  given  as  250.  In  1867,  when  the  popu- 
lation was  22,000,  the  deaths  from  yellow  fever  were  1 1 50.  From 
the  constant  manner  in  which  epidemics  succeeded  one  another, 
it  is  very  probable  that  the  disease  gained  an  endemic  foothold. 
On  the  other  hand,  Galveston  was  a  port  very  liable  to  continuous 
infection  from  without. 

Since  1870  the  disease  has  not  appeared  in  epidemic  form, 
but  histories  of  imported  cases  have  been  frequently  recorded. 

References 
AUGUSTIN  (G.) — History  of  Yellow  Fever,  New  Orleans,  1909. 
Carey  (M.) — Short  Account  of  the  Malignant  Fever  lately  prevalent  in 

Philadelphia. 
Keating  (J.  M.) — History  of  a  Yellow  Fever  Epidemic  of  '1878,  in  Memphis, 

Tetin. 
La  Roche  (R.) —  Yellow  Fever,  Philadelphia. 

New  Orleans. — There  is  every  reason  to  believe  that  this 
city,  during  its  very  early  history  and  occupation  by  the  French 
and  Spanish  in  the  eighteenth  century,  was  regularly  visited  by 
yellow  fever.  Not,  however,  until  the  city  enlarged  in  the 
nineteenth  century,  as  the  result  of  commercial  development  in 
connection  with  cotton  and  sugar,  did  yellow  fever  attain  the 
proportions  that  rendered  it  notorious.  From  the  year  1822, 
probably  from  a  still  earlier  date,  there  is  an  unbroken  record  of 
outbreaks  and  epidemics  until  i860.  During  those  thirty-eight 
years  we  may  safely  assume  that  yellow  fever  had  become 
endemic,  that  conditions  existed  in  the  slums  of  the  old  Gulf 


NEW  ORLEANS  29 

port,   which  enabled   the   Stegomyia  to   tide    over   the   winter 
season. 

After  i860  there  was  a  fall  in  the  annual  mortality  from 
yellow  fever,  but  outbreaks  were  recorded  in  1867,  1874.  In 
1878  an  epidemic  occurred,  with  a  record  of  4046  deaths;  in 
1897,  298  deaths  took  place.  Between  this  date  and  the  last 
epidemic  in  1905  the  notification  of  cases  of  yellow  fever  was 
frequently  made.  So  that  there  is  the  possibility  that  from  1822 
to  1905  the  disease  existed  in  an  endemic  form  in  the  city. 
During  this  period,  however,  there  were  no  doubt  countless 
opportunities  for  imported  infection  by  ships  arriving  from 
Havana  and  other  infected  ports. 

References 
New  Orleans  Medical  and  Surgical  Journal,  various  numbers. 
AUGUSTIN  (G.) — History  of  Yellow  Fever,  New  Orleans,  1909. 
Boyce   (Sir   R.   W.) — Yellow  Fever  Prophylaxis  in  New  Orleans,  1905; 

Memoir  XIX.,  Liverpool  School  of  Trop.  Medicine. 
Thomas  (P.  F.) — Traite 'pratique  de  lafievrejaune  observee  a  la  Nouvelle 

Orleans,  Paris,  1848. 
Report  of  the  Commission  of  New  Orleans  on  the  Epide7nic  of  Yellow  Fever 

0/1853,  New  Orleans,  1854. 
Faget  (J.  C.) — Fievre  Jaune,  Paris,  1875. 

Mobile,  Alabama. — From  the  end  of  the  eighteenth  century 
into  the  early  part  of  the  nineteenth  century,  and  at  a  subsequent 
period,  there  is  evidence  in  favour  of  yellow  fever  having  been 
endemic  for  a  number  of  years.  It  has  long  ceased  to  be 
endemic. 

Pensacola,  Florida. — Here  also  there  is  evidence  in  the  nine- 
teenth century  of  endemic  yellow  fever  existing  for  a  number  of 
years.     There  was  a  considerable  outbreak  in  1905. 

Key  West,  Florida. — The  seat  of  constant  small  outbreaks  in 
the  nineteenth  century. 

From  the  preceding  evidence  there  is  much  in  favour  of 
yellow  fever  having  gained  a  temporary  endemic  foothold  in 
the   Gulf  ports.     Climatic  conditions  to  commence  with,   and 


30  YELLOW  FEVER  IN  NORTH  AMERICA 

subsequently  the  introduction  of  stricter  hygiene  and  better 
water  supplies,  turned  the  scale  against  the  Stegomyia,  and  the 
endemic  character  of  the  disease  disappeared,  although  small 
outbreaks  continued  to  occur  at  intervals. 

Atlantic  Ports — Charleston,  South  Carolina. — Yellow  fever 
was  of  constant  occurrence  in  the  nineteenth  century — so  regular, 
that  in  all  probability  it  was  for  some  time  endemic. 

Baltimore,  Maryland. — As  has  so  frequently  happened  in 
other  parts  of  the  world  where  yellow  fever  is  liable  to  occur, 
there  has  long  been  present  in  Baltimore  a  fever  which  was 
known  as  bilious  remittent,  but  which,  there  is  now  good  reason 
to  suppose,  might  have  equally  well  been  a  mild  form  of  yellow 
fever.  Other  significant  facts  recorded  are  that  the  bilious 
remittent  fever  originated  in  and  usually  remained  confined  to 
the  squalid,  overcrowded,  exceedingly  ill-kept  quarters  in  the 
port,  and  that  the  abundance  of  mosquitos  was  a  matter  of 
comment,  and  that  the  physicians  of  the  period  were  in  favour  of 
the  local  rather  than  the  imported  origin  of  the  disease. 

On  the  whole,  the  evidence  is  in  favour  of  yellow  fever  having 
been  endemic  for  a  number  of  years,  the  Stegomyia  persisting  in 
the  overheated,  overcrowded  slums  close  to  the  wharves.  One 
of  the  earliest  and  most  severe  epidemics  occurred  in  1794,  when 
there  were  360  deaths ;  another  severe  epidemic  took  place  in 
1800,  when  there  were  11 97  deaths.  Through  the  eighteenth 
century  small  outbreaks  or  sporadic  cases  were  repeatedly 
recorded  up  to  the  year  1876. 

References 
MORRIS   (J.) — Transactions  American    Public    Health  Association,    1877- 

1878. 
Carroll  (J.)— Old  Maryland,  1906,  vol.  ii. 
AuGUSTlN  (G.) — History  of  Yellow  Fever. 

Philadelphia. — This  city  also  furnishes  another  proof  that 
conditions  existed  at  the  end  of  the  eighteenth  century  and 
through  the  nineteenth  century — in  fact,  from  its  foundation — 


ATLANTIC  PORTS 


31 


that  allowed  the  Stegomyia  to  persist  from  one  year  to  another, 
for  there  can  be  little  question  that  yellow  fever  for  a  period 
became  endemic,  viz. — 


1699  . 

220  deaths 

1741 

240   „ 

1793  . 

4044   ,, 

1797 

1292    „ 

1793  . 

35o6   „ 

1799  . 

1015    „ 

1803  . 

3900   „ 

These  very  high  death-rates  signified  that,  owing  to  the  constant 
tide  of  immigration  at  the  period,  there  were  always  present 
non-immunes  in  large  numbers.  For  this  was  the  period  when 
the  little  settlement  of  3000  was  growing  into  a  great  city  of 
100,000,  in  the  first  decade  of  the  nineteenth  century.  This  was 
also  a  period  when  wells  abounded  and  drainage  hardly  existed, 
and  refugees  were  pouring  in  from  the  disturbed  West  Indies. 
It  was  also  noted  at  this  period  that  whilst  the  newcomers 
from  Europe  contracted  the  disease,  those  from  the  West 
Indies  remained  free — no  doubt,  because  they  were  immune, 
having  already  had  the  disease. 

References 
Augustin  (G.) — History  of  Yellow  Fever,  New  Orleans,  1809. 
RUSH    (B.) — Medical    Enquiries    and    Observations,     Philadelphia,     1809 

(4  vols.)  ;  consisting  of  essays  on  the  non-contagiousness  of  yellow 

fever  and  accounts  of  various  epidemics  and  sporadic  cases,  also  other 

works  by  the  same  author. 
Second  Report  on  Quarantine,  1852.     Gillkrest  on  opinion  of  physicians  of 

America  on  yellow  fever. 
Rush  (B.) — An  Account  of  the  Bilious  Re?nittent  or  Yellow  Fever  as  it 

appeared  in  Philadelphia  in  1793,  Philadelphia,  1794. 

New  York. — During  the  growth  of  this  town  from  a  village 
to  a  metropolis,  commencing  at  the  end  of  the  seventeenth 
century  and  passing  through  the  eighteenth  and  nineteenth 
centuries,  there  is  a  long  record  of  outbreaks. 

Some  of  the  epidemics  were  of  large  dimensions.     In  1668 


32  YELLOW  FEVER  IN  NORTH  AMERICA 

there  were  370  deaths;  in  1803,  606  deaths;  in  1856,  538 
deaths.  In  1870  an  outbreak  also  occurred.  The  disease,  as  in 
the  case  of  Baltimore,  possessed  a  focal  character,  indicating 
that  in  a  particular  locality  conditions  existed  for  the  survival 
and  even  multiplication  of  the  mosquito.  In  the  case  of  New 
York,  the  evidence  is  not  conclusive  enough  to  enable  it  to  be 
said  that  yellow  fever  had  gained  an  endemic  foothold. 

It  can  be  said,  however,  that  conditions  existed  which  made 
it  possible  for  the  Stegomyia  to  multiply  in  large  numbers  in 
certain  localities  (see  ante),  so  that  if  yellow  fever  was  introduced 

it  could  readily  spread. 

Reference 
Augustin  (G.)— Loc.  cit. 

Boston. — In  this  town  the  history  of  yellow  fever  shows  that 
the  outbreaks  were  comparatively  small,  and  for  the  most  part 
limited  to  the  ships,  and  in  all  probability  to  the  immediate 
neighbourhood  of  the  shipping.  It  shows  that  the  imported 
Stegomyia  was  not  able  to  gain  a  continuous  foothold,  but  that 
in  certain  favourable  seasons  it  was  capable  of  multiplying,  and 
therefore  capable  of  giving  rise  to  a  localised  outbreak,  much  as 
in  the  case  of  the  seaports  in  Europe. 

References 
Augustin  (G.) — Loc.  cit. 
Medical  Repository,  several  vols. 


CHAPTER  V 

HISTORY   OF  YELLOW  FEVER  IN   EUROPE 

The  appearance,  progress,  and  disappearance  of  yellow  fever 
in  Europe  in  the  eighteenth  and  nineteenth  centuries  teaches 
tie  the  same  instructive  lesson  as  did  North  America.  For  the 
same  reason  as  in  that  continent,  and  from  much  the  same 
causes,  yellow  fever  gained  a  series  of  temporary  footholds.  It 
is  somewhat  doubtful,  however,  whether  it  ever  became  endemic ; 
but  it  certainly  was  often  epidemic  and  raged  with  great 
violence,  and  the  outbreaks  succeeded  one  another  with  great 
frequency.  The  causes  which  led  to  the  appearance  of  the 
disease  were  those  which  operated  in  North  America — growth 
of  commercial  intercourse,  and  the  emigration  of  colonists  to 
the  West  Indies,  Central  America,  and  Brazil,  at  first  chiefly 
derived  from  the  Peninsula  and  Italy,  then  from  France,  and 
later  on  from  North  Europe.  As  the  Latin  races  had  been 
first  to  colonise  in  the  New  World,  so  they  were  the  first,  when 
returning  home,  to  import  yellow  fever  into  the  Old  World. 

In  the  eighteenth  and  nineteenth  centuries  the  hygienic 
conditions  of  the  chief  ports  of  Spain,  Portugal,  Italy,  and  the 
South  of  France  were  very  primitive.  As  in  North  America, 
so  here,  there  existed  overcrowded  filthy  quarters,  to  be  found 
in  the  old  South  European  ports  close  to  the  shipping  ;  and  from 
observation  of  to-day  it  is  easy  to  understand  how  readily  the 
Stegomyia  could  have  swarmed  in  the  warm  months  of  the  year, 
and  how  even  they  could  have  survived  through  the  winter 
time,  in  the  hot,  overcrowded  houses  in  the  poorer  parts  of  the 

33  c 


34        HISTORY  OF  YELLOW  FEVER  IN  EUROPE 

seaports.  Infection  was  then  of  almost  daily  occurrence,  for 
each  sailing  vessel  returning  from  Cuba  and  the  West  Indies, 
or  Central  America  and  Brazil,  was  almost  certain  to  have  cases 
of  yellow  fever  on  board,  as  well  as  numbers  of  infected 
Stegomyia ;  so  that  although  a  considerable  distance  existed 
in  time  and  space  between  the  infected  foci  and  the  Spanish 
ports,  nevertheless  the  constant  arrival  of  infected  ships  brought 
the  endemic  foci  very  close  to  Europe. 

There  appears  to  be  considerable  evidence  that  yellow  fever 
was  known  as  early  as  the  sixteenth  century  in  Spain,  epidemics 
of  what  might  have  been  the  disease  being  recorded  in  1501, 
1 5 15,  and  1589.  But  in  order  to  marshal  the  well-authenticated 
facts,  I  will  describe  the  progress  of  the  disease  in  Cadiz, 
Malaga,  Cartagena,  Gibraltar,  Majorca,  Lisbon,  and  Barcelona  ; 
Leghorn  in  Italy  ;  Marseilles,  Brest,  St  Nazaire,  in  France ;  and 
Swansea  and  Southampton  in  England. 

It  is  quite  possible  that  yellow  fever  might  have  been 
brought  in  in  the  sixteenth  century  with  the  ships  returning 
from  the  New  World  in  that  century. 

References 

HURT  ADO — Neuva  monografia  and  Decadas. 

DOUGHTY — Observations  and  Enquiries  into  the  Nature  and  Treatment  of 

Yellow  (Bulam)  Fever,  London,  18 16. 
O'HALLORAN — On  the  Yellow  Fever  of  the  South  and  East  Coasts  of  Spain. 
FERMON  (Dr  de),  Revue  critique,  Paris,  1829. 
PARISET — Histoire  medicate. 
Augustin  (G.) — History  of  Yellow  Fever. 

Gillkrest  in  The  Second  Report  on  Quarantine,  London,  1852. 
Reports   on  the  Pathology,  Therapeutics,  and   General  Etiology  of  the 

Epidemic  of  Yellow  Fever  which  prevailed  in  Lisbon,  1857,  Brit,  and 

Foreign  Med.  Review,  voL  xxv.,  i860. 

Cadis. — Yellow  fever  is  stated  to  have  broken  out  in  1730, 
1731.  1736,  1764,  1800,  1802,  1805,  and  1810.  Investigations 
were  made  into  the  nature  of  the  epidemics  of  1730-173 1. 
Inquiry    into    the     18 10   epidemic    showed    that    in    the    six 


SPAIN  35 

outbreaks  previous  to  1805  the  original  source  of  infection 
could  not  then  be  traced.  In  1761  an  official  report  stated  that 
from  the  experience  of  the  trade  relationship  between  Havanna 
and  Cadiz,  yellow  fever  could  not  be  regarded  as  a  contagious 
disease.  Other  epidemics  followed  in  18 13,  18 19,  and  1821  ;  the 
latter  date  appears  to  be  the  last  of  the  epidemics. 

Deveze,  in  his  traite,  gives  an  account  of  the  symptoms  of  the 
epidemic  of  1800. 

References 
VlLLALBA — Epidemiologia  espanola. 
Gillkrest  in  The  Report  on  Quarantine,  1852. 
Deveze  (Jean) — Traite  de  la  fievrejaune,  Paris,  1820. 
AREJULA  (J.  Manuel  de) — Breve  descripcion  de  lafiebre  amarilla  padecida 

en  Cadiz  y  pueblos  camarcanos  en  1800,  en  Medinasidonia  en  1801,  e7i 

Malaga  en  1 803,  y  en  esta  misma  plaza  y  varios  otros  del  regno  on 

1804. 
Fellowes  (Sir  James) — Reports  on  the  Pestilential  Disorder  of  Andalusia, 

at  Cadiz,  1800,  1804,  1810,  1813,  London,  1815. 


Malaga,  Cartagena,  and  Passages. — These  are  also  South 
Spanish  ports  which  were  frequently  infected  in  the  eighteenth 
and  nineteenth  centuries  by  returning  ships.  Therefore,  as  at 
Cadiz,  the  Stegomyia  must  have  found  suitable  conditions  for 
propagation.  Outbreaks  of  black  vomit  are  chronicled  at 
Malaga  in  1741,  1803,  and  1810;  but  even  at  an  earlier  date 
(1678- 1688)  the  port  was  visited  by  an  epidemic  which  might 
have  been  yellow  fever. 

The  ports  of  Cartagena  and  Valencia  are  said  to  have  been 
visited  by  an  epidemic  in  1648,  and  epidemics  are  recorded  at 
Cartagena  in  1804-18 12.  Yellow  fever  broke  out  at  the  little 
port  of  Passages ;  it  is  stated  that  at  that  time  the  houses  in 
Passages  were  crowded,  filthy,  and  badly  ventilated.  Previous 
outbreaks  are  stated  to  have  occurred  in  1780  and  1791,  and 
even  in  the  periods  1808- 1809  and  18 13-18 14  both  English  and 
French  troops  quartered  there  are  said  to  have  suffered  from  a 
fever  which  might  have  been  yellow  fever. 


36        HISTORY  OF  YELLOW  FEVER  IN  EUROPE 

References 
GlLLKREST  in  The  Second  Report  on  Quarantine,  1852. 
Bally — Histoire  medicate  de  la  fievre  jaune,  Paris,  1823. 
AUDOUARD  (F.  M.) — Relation  historique  et  medical  de  la  fievre  jaune  qui  a 
regnee  a  Barcelona  en  1821. 

Barcelona. — The  history  of  yellow  fever  does  not  go  so  far 
back  as  in  the  case  of  the  other  seaports,  but  it  gained  in 
intensity  in  the  nineteenth  century,  related  without  doubt  to 
the  very  rapid  commercial  progress  of  that  seaport.  Outbreaks 
were  recorded  in  1803  and  18 10.  The  great  epidemic  occurred 
in  1 82 1,  and  attracted  at  the  time  investigators  from  many 
countries — French,  British,  and  American. 

The  disease  was  imported  by  ships  returning  from  Havanna, 
and  the  history  of  its  development  is  that  of  all  similar  towns — 
at  first  the  shipping  people  and  those  who  visited  the  ships, 
then  the  dwellers  in  surrounding  houses.  The  population  of 
Barcelona  was  then  150,000,  of  which  only  70,000  remained  in 
the  port  during  the  fever,  and  of  these  20,000  are  stated  to 
have  died  of  the  disease.  In  1870  and  1883,  small  outbreaks 
occurred  amongst  the  crew  and  workmen  discharging  infected 
ships  in  the  port. 

References 

O'HALLORAN — Remarks  on  the  Yellow  Fever  in  the  South  and  East  Coasts 

of  Spain,  London,  1823. 
AUDOUARD  (F.  M.) — Relation  historique  et  medical  de  la  fievre  jaune  qui  a 

regnee  a  Barcelona  en  1871. 
BALLY — Histoire  medicate  de  la  fievre  jaune,  Paris,  1823. 

Palma  (in  Majorca)  was  infected  during  the  great 
epidemic  of  Barcelona,  which  swept  over  Southern  Spain. 
Previous  invasions  were  recorded  in  the  early  part  of  the 
nineteenth  century. 

Gibraltar. — The  epidemics  of  yellow  fever  which  once  pre- 
vailed at  this  military  station  attracted  a  great  deal  of  attention  in 
the  early  part  of  the  nineteenth  century,  and  there  are  numerous 
official  reports  and  documents  available  in  connection  with  it. 


GIBRALTAR  37 

The  history  of  yellow  fever  at  Gibraltar  has  a  very  great 
scientific  interest,  for  it  tends  to  show  that  that  disease  had 
actually  become  endemic  for  a  time,  just  as  we  have  seen  in 
the  case  of  certain  Gulf  ports  in  the  Southern  States  of  North 
America.  If  old  accounts  are  to  be  trusted,  yellow  fever 
appeared  as  early  as  1649.  In  1727  there  was  an  epidemic  of 
doubtful  nature,  of  which  500  of  the  garrison  died. 

In  1798  and  1799  a  disease  precisely  similar  to  that  well 
known  in  the  West  Indies  produced  great  mortality  amongst 
the  newly  arrived  regiments.  In  1800,  257  deaths  occurred 
from  the  same  fever  in  the  garrison.  In  1804  a  severe 
epidemic  occurred:  of  a  population  of  15,000,  4864  civilians 
and  869  soldiers  died. 

In  1 81 3  there  were  899  deaths.  In  the  intervals  between  the 
epidemics  from  1800,  it  appears  upon  the  statement  of 
Gillkrest  {Joe.  cit.)  that  sporadic  cases  of  the  disease  were  of 
annual  occurrence.  If  the  observations  were  correct,  it  would 
appear  that  the  disease  had  gained  an  endemic  foothold.  It  is 
worthy  of  note  that  it  was  observed  that  the  progress  of  yellow 
fever  was  stopped,  as  it  is  always  found  to  be,  by  the  setting  in  of 
a  cold  wind  from  the  North. 

A  military  port  like  Gibraltar  was,  it  must  be  well  under- 
stood, extremely  liable  to  infection  from  without,  not  only  by 
troopships  returning  from  the  West  Indies  and  Africa,  but  also 
by  ships  arriving  from  infected  ports  in  Spain. 

The  1828  epidemic  was  remarkable  for  having  brought  to  a 
head  the  fierce  controversy  which  raged  at  the  time  as  to 
whether  yellow  fever  was  contagious  or  non-contagious.  It  is 
obvious  that  experienced  observers  and  clinicians,  not  suspect- 
ing that  the  disease  was  mosquito-carried,  were  all  the  time  at 
a  complete  loss  how  to  explain  fully  the  sudden  appearance, 
curious  mode  of  spreading,  and  sudden  disappearance  of  the 
disease.  The  majority  of  observers  were  certain,  as  will  be 
shown  in  another  chapter,  that  the  disease  was  not  contagious. 
On  the  other  hand,  great  observers  were  equally  certain  that 


38        HISTORY  OF  YELLOW  FEVER  IN  EUROPE 

the  disease  could  be  carried  from  point  to  point  by  infected 
persons.  Both  schools  of  investigators  were  correct  in  their 
facts ;  the  missing  link  in  the  contradictory  views  was  the 
unsuspected  mosquito,  as  we  shall  see.  In  this  epidemic  it  was 
noted  by  Gillkrest  how,  over  and  over  again,  those  members  of 
a  family  who  nursed  those  of  them  who  were  sick  very  often 
escaped  ;  wives  slept  with  their  infected  husbands,  and  mothers 
with  their  sick  children,  yet  they  by  no  means  always  contracted 
the  disease. 

The  non-contagionists  laid  great  stress  upon  the  local 
origin  of  the  disease,  a  belief  which  has  survived  even  up  to 
the  present  time  in  many  parts  of  the  world.  It  was  also  noted 
how  those  of  a  family  living  in  the  upper  storey  of  a  house 
often  escaped,  whilst  those  on  the  ground  floors  became 
infected.  The  want  of  complete  protection  afforded  by  isolating 
the  non-infected  from  the  infected  was  also  often  observed 
during  the  progress  of  the  epidemic.  The  non-contagionists  laid 
stress  upon  the  fact  that  in  the  epidemics  in  Spain  the  advent  of 
cold  weather  caused  the  outbreak  to  decline  ;  they  reasoned  that 
the  heat  favoured  the  local  or  miasmatic  cause.  They  further 
noted  how  yellow  fever  clung  to  certain  localities  and  even 
houses  ;  then  in  despair  Gillkrest  exclaims,  "  It  must  be  confessed 
by  all  unprejudiced  persons,  that  the  closest  investigations 
have  failed  in  the  discovery  of  the  sine  qua  non  cause  of  yellow 
fever.  And,  as  for  the  contagionists,"  he  added,  "  they  may 
dwell  on  the  exotic  origin  of  yellow  fever,  but  they  have  always 
a  secret  feeling  that  its  development  is  dependent  upon  an 
assemblage  of  circumstances.  In  a  few  words,  we  may  say 
with  Arejula,  while  the  days  lengthen  and  the  sun  approaches 
our  hemisphere,  we  may  be  sure  that  the  fever,  which  has  so 
afflicted  us  of  late  years,  will  not  attack  us ;  but  when  that 
luminary  begins  to  retire  from  us,  and  during  the  whole  period 
of  its  retiring,  we  may  fear  it,  especially  if  we  have  had  a 
sterile  season,  and  if  hot  and  dry  winds  have  prevailed  for  many 
days  successively ; "   and   with    many  more    arguments   of  the 


MALTA  39 

same  nature  the  contagionists  and  non-contagionists  groped 
along  until  the  sine  qua  non  cause  was  discovered  many  years 
afterwards. 

The  following  note  by  my  colleague,  Professor  Robert 
Newstead,  is  of  interest  because  it  shows  that  the  Stegomyia 
still  survives  (1910)  in  Southern  Europe,  and  clearly  demon- 
strates how  it  was  possible  for  large  epidemics  of  yellow  fever 
to  break  out  in  Southern  Europe. 

"  Stegomyia  fasciata  (calopus) "  in  Malta 

"  The  mosquito  was  decidedly  the  commonest  species  which 
frequented  the  dwellings  of  man  in  Valetta  during  the  months 
of  July,  August,  and  the  beginning  of  September,  and  was  found 
to  be  more  domesticated  than  either  Culex  fatigans  or  C 
pipiens.  Its  favourite  breeding-places  are  shallow  receptacles 
in  yards  and  gardens,  tanks,  fire-buckets  in  hospitals,  or  in  any 
receptacle  holding  water  which  had  been  left  unchanged  for  a 
few  days.  A  vessel  of  water  left  in  a  bedroom  for  a  few  days 
was  found  to  contain  a  number  of  larvae  of  this  mosquito ;  these 
subsequently  produced  imagines,  so  that  there  can  be  no  doubt 
as  to  the  identity  of  the  insect. 

"  The  commoner  species  of  mosquitos  met  with  in  Malta 
are — 

(1)  Culex  pipiens \ 

(2)  Culex fatigans \ 

(  3  )  Stegomyia  fasciata, 

of  which  the  last  named  formed  16-5  per  cent  of  the  captures. 

"  Culex  pipiens  is  by  far  the  commonest  species,  and  was  found 
breeding  in  enormous  numbers  in  cesspools.  It  was  rarely  seen 
in  the  main  dwellings,  being  much  less  frequently  seen  in  such 
places  than  either  the  Stegomyia  or  its  near  relative,  Culex 
fatigans. 

"  The  imagines  make  their  appearance  in  some  numbers 
usually  at  the  end  of  May,  and  are  said  to  be  most  plentiful 
during  the  month  of  June.  In  the  year  1906,  for  some  un- 
accountable reason,  this  mosquito  was  rarely  found  until  the 
month  of  August;  but  during  my  stay  in  the  island  (1910)  it 


40        HISTORY  OF  YELLOW  FEVER  IN  EUROPE 

was  present  during  the  months  of  July,  August,  and  September. 
I  was  informed  on  good  authority  that  imagines  also  occur 
during  the  winter  months,  so  that  in  all  probability  this  species 
hybernates  in  the  adult  stage  during  the  cooler  months  of  the 
year,  a  habit  common  to  many  species  in  the  colder  portions  of 
Europe.  I  can  find  no  records  of  its  occurrence  in  the  larval 
stage  during  winter,  but  it  is  just  possible  that  they  do  so, 
seeing  that  there  are  no  frosts  in  Malta,  though  the  temperature 
may  be  very  low  at  times." 

When  trade  routes  became  diverted  from  the  southern  parts 
of  Europe  to  the  more  northern,  we  find  yellow  fever  in  France 
penetrating  to  the  ports  of  Brest  in  1802,  l'Orientand  St  Nazaire 
in  1 861,  and  even  in  England,  at  Swansea,  in  1865.  These  out- 
breaks, however,  are  strictly  limited  to  the  ships  which  brought 
the  infected  cases  or  the  infected  Stegomyia. 

It  is  not  a  question  of  the  Stegomyia  breeding  in  any  of 
these  seaports.  The  climatic  conditions  render  that  impossible. 
A  ship  coming  from  a  yellow  fever  centre  in  the  West  Indies, 
or  from  Brazil,  came  into  port.  Infected  Stegomyia  were  living 
on  board  just  as  they  would  have  done  in  the  West  Indian  town 
from  whence  they  came.  In  other  words,  the  ship  was  but  a 
floating  infected  house,  the  conditions  on  board  being  suitable 
to  the  developmental  cycle  of  the  Stegomyia,  both  as  regards 
temperature,  water  and  food  supply,  very  much  as  on  shore  in 
a  tropical  town.  If,  therefore,  labourers  or  visitors  went  on 
board  and  moved  about  the  interior  of  the  ship,  or  commenced 
to  work  the  cargo  in  the  holds,  they  naturally  exposed  them- 
selves to  infection,  and  an  outbreak  of  yellow  fever  took  place, 
not  from  yellow  fever  contracted  in  the  town,  but  from  the  bites 
of  the  infected  Stegomyia  on  the  ship.  When  the  ship  left  the 
port  nothing  was  heard  of  the  disease,  unless  by  some  stray 
chance  an  infected  Stegomyia  had  escaped  from  the  ship  to 
an  adjacent  goods  shed  or  labourer's  cottage  close  by  the 
wharf,  when  of  course  it  might  equally  well  infect  those  whom 
it  bit. 


FRANCE  41 

In  1909  an  outbreak  occurred  at  St  Nazaire,  due  to  infected 
Stegomyia,  and,  like  all  previous  ones,  limited  to  the  ship  and 
those  who  come  in  contact  with  it,  and  exposed  themselves 
to  the  bites  of  the  infected  Stegomyia  which  had  been  taken 
on  board  at  Martinique  during  the  epidemic  in  that  island 
in  1909. 


CHAPTER   VI 

HISTORY   OF   YELLOW   FEVER   ON    SHIPS 

A  CONSIDERATION  of  the  mode  in  which  yellow  fever  is  carried 
shows  that  it  is  par  excellence  a  disease  especially  suitable  for 
transport  by  ships,  especially  by  the  sailing-ships  common  in 
the  fifteenth  and  sixteenth  centuries. 

The  history  of  yellow  fever  shows  that  it  was  as  a  matter  of 
fact  one  of  the  most  frequent  of  the  diseases  common  to  ships 
in  those  centuries ;  so  common  that  "  ship's  fever  "  or  "  yellow 
jack  "  were  the  familiar  names  for  yellow  fever. 

Moreover,  because  yellow  fever  was  of  such  frequent  occur- 
rence on  ships  when  far  out  at  sea,  a  few  medical  men  to-day 
reason  that  the  disease  cannot  be  mosquito-carried,  but  must 
be  due  to  some  miasm  arising  from  waterlogged  ballast  or 
special  cargoes,  or  from  the  bilge.  As  a  matter  of  fact  we  know 
that  the  Stegomyia  calopus  is  very  frequently  found  on  ships, 
and  that  it  can  be  transported  alive  with  great  ease  over  long 
distances.  Given  a  ship  which  has  to  remain  against  a  wharf,  or 
alongside  of  which  lighters  come  off  from  the  shore  to  discharge 
and  load,  it  has  been  proved  that  the  Stegomyia,  in  common 
with  other  mosquitos,  readily  enters  the  ship.  It  is  for  this 
very  reason  that  ships  trading  with  mosquito-breeding  ports 
are  now  being  screened,  and  that  the  officers  usually  sleep  under 
mosquito  nets. 

Careful  and  systematic  search  has  been  made  of  the  holds, 
engine  room,  galley,  sleeping  and  living  quarters  of  the  crew 
and    officers  of  ships  arriving   from   mosquito   coasts,  and  the 


STEGOMYIA  ON  SHIPS  43 

Stegomyia  has  been  repeatedly  found.  Eighty-two  vessels 
coming  from  ports  infected  with  Stegomyia  were  subjected  to 
careful  examination,  and  in  spite  of  the  fact  that  the  voyage  had 
lasted  from  13-20  days.  The  Stegomyia  was  found  by  Dr 
Grubbs  in  three  cases ;  Dr  King  of  St  Lucia  also  found  living 
Stegomyia  in  ships  coming  from  Barbados  in  1909,  Dr  Durham 
on  ships  trading  on  the  Amazon.  I  met  with  a  similar  instance 
in  the  case  of  a  steamer  which  sailed  from  Belize  in  1906. 

Therefore  it  is  beyond  dispute  that  living  Stegomyia  may 
be  carried  great  distances  over  sea  by  means  of  ships.  In  the 
old  days  of  sailing-ships  there  was,  however,  another  factor 
which  made  it  a  matter  of  certainty  that  ships  trading  in  the 
tropics  not  only  could  transport  Stegomyia,  but  also  breed  them 
during  the  voyage. 

In  the  sailing  ship  days  it  was  not  a  question  of  condensation 
water,  it  was  imperative  to  store  drinking  water  in  numerous 
casks  and  tanks  for  the  long  voyage.  There  were  no  artificial 
mineral  waters  ;  reliance  had  to  be  placed  on  the  storage  tanks 
and  casks,  or  the  rain  water  collected  in  the  sail  during  the 
voyage. 

But  this  class  of  water  is  precisely  the  kind  in  which  the 
adult  female  mosquito  deposits  her  eggs.  Therefore,  if  a 
mosquito  was  once  introduced  on  board,  it  could  propagate 
freely ;  further,  as  very  often  the  stock  of  water  was  renewed  at 
the  ports  of  call  in  the  Stegomyia  zone,  both  larvae  and  eggs  of 
Stegomyia  were  no  doubt  taken  on  board  together  with  the 
water. 

For  practical  purposes,  in  the  old-time  wooden  ships,  the 
Stegomyia  found  as  satisfactory  a  breeding-ground  as  in  any 
village  on  shore,  and  if  anything  the  food  supply,  i.e.,  man's 
blood,  was  nearer  at  hand  than  on  shore.  No  wonder  then  that 
yellow  fever  was  the  shifts  fever  of  the  eighteenth  and  nineteenth 
centuries,  and  that  the  history  of  yellow  fever  abounds  with 
innumerable  instances  of  the  then  supposed  or  real  transmission 
of  yellow  fever  from  one  port  to  another.     The  slave-ships  were 


44  HISTORY  OF  YELLOW  FEVER  ON  SHIPS 

very  rightly  looked  upon  with  great  suspicion,  and  one  writer 
went  so  far  as  to  state  that  yellow  fever  was  the  price  which 
Europe  paid  for  the  slave  trade.  No  doubt  the  old  slave-ships 
were  infested  with  Stegomyia. 

The  Frigates  were  also  especially  prone  to  foster  yellow  fever 
and  the  naval  medical  records  teem  with  innumerable  instances 
of  the  outbreaks  of  yellow  fever  on  board.  Indeed,  so  bad  did 
the  reputation  of  some  ships  become  in  the  service,  that  they 
had  to  be  ultimately  abandoned  and  scuttled,  for  it  was  thought 
that  the  yellow  fever  miasms  actually  clung  to  their  timbers. 

Another  factor  which  greatly  conduced  in  the  sailing-ship 
days  to  mosquitos  getting  on  board,  was  the  length  of  time 
which  the  ships  remained  in  ports  to  load  and  unload.  Since 
steam  iron  ships  have  replaced  wooden  ships,  the  danger  of 
carrying  infected  mosquitos  has  greatly  lessened,  and  still  less 
of  course  is  the  chance  of  breeding  them  on  board,  for  the 
drinking  water  is  to  a  large  extent  obtained  by  condensation. 

In  consequence,  yellow  fever  is  now  comparatively  rare  on 
ships,  instead  of  the  rule. 

This  fact  alone  proves  very  conclusively  the  relationship  of 
the  Stegomyia  to  yellow  fever.  In  spite,  however,  of  its  rarity, 
yellow  fever  does  from  time  to  time  break  out  on  board  ship. 
It  is  of  course  obvious  that  a  passenger  or  member  of  the  crew 
may  leave  an  infected  port  with  infection,  and  the  disease  may 
develop  in  transit ;  such  a  case  corresponds  to  an  imported  case 
on  land.  But  if  there  are  Stegomyia  on  board,  they  can  spread 
the  disease  from  the  infected  person  to  others  on  board,  or 
infected  Stegomyia  taken  in  at  the  port  of  departure  may  live 
for  weeks  in  the  ship,  and  when  finally  disturbed  at  the  end  of 
the  voyage,  or  during  transit,  start  an  outbreak.  There  are 
innumerable  instances  of  the  latter  method  of  outbreaks. 
Examples  are  found  at  Marseilles,  Brest,  Saint  Nazaire  (1909), 
Swansea,  etc.,  etc.  (see  also  preceding  chapter). 

The  following  are  a  few  of  the  chief  outbreaks  of  yellow 
fever    on    ships.       In     1726    a    great    outbreak    occurred     on 


STEGOMYIA  ON  SHIPS  45 

our  fleet  lying  off  Porto  Bello,  from  probably  yellow  fever. 
In  1741  an  outbreak  on  the  fleet  under  Admiral  Vernon  off 
Cartagena  ;  again  in  this  same  fleet  off  Porto  Bello  in  1742.  In 
1776  in  Spanish  ships  Ay  el  and  Astrea  on  their  way  out  to  the 
West  Indies.  In  1783  an  outbreak  on  the  Spanish  fleet.  In 
1785  on  a  Spanish  ship.  In  1793  on  a  Spanish  cruiser  bound 
from  Cadiz  to  the  West  Indies,  and  also  on  a  Spanish  squadron. 
In  1794  on  two  British  war-ships.  In  1801  on  board  a  ship 
carrying  Irish  emigrants  to  New  York.  In  1802  on  a  French 
fleet  bound  from  Tarentum  to  St  Domingo.  In  1803  on  a 
ship  from  Portsmouth  to  New  York.  In  1802  on  the  Spanish 
fleet.  In  1807  in  a  French  squadron  in  the  bay  of  Cadiz. 
In  1 8 14  in  a  squadron  of  Spanish  cruisers.  From  this  date  to 
the  middle  of  the  nineteenth  century,  on  innumerable  occasions 
upon  crusiers  and  ships  trading  in  the  West  Indies  and  on  the 
West  African  coast.  After  1850,  steamships  replaced  the  sail- 
ing ship,  and  later  on  iron  replaced  wood,  and  from  that  time 
yellow  fever  became  rarer  and  rarer  on  board  ship ;  but  even 
to-day  occasional  outbreaks  are  recorded  during  the  passage  or 
on  arrival  at  port. 

It  will  be  noticed  that  in  many  instances  yellow  fever 
broke  out  on  the  departure  of  ships  from  a  northern  port. 
This  is  explicable  by  the  ship  having  previously  come  from 
some  yellow  fever  port,  such  as  from  the  West  Indies.  The 
infected  Stegomyia  could  remain  alive  and  infectious  for  several 
weeks,  and  perhaps  months  in  the  cabins  and  galleys. 

In  order  to  obviate  the  risk  of  infected  Stegomyia  getting  on 
board  ships,  the  latter  should  be  anchored  as  far  off  wharves  as 
possible,  compatible  with  business  requirements,  and  should 
remain  as  short  a  time  as  possible. 

Those  living  on  board  should  also  be  all  provided  with 
mosquito  nets :  some  of  the  latest  ships  are  provided  with  wire 
gauze  screens  to  the  ports,  allyways,  and  ventilators.  It  is  also 
proper  to  fumigate  all  parts  of  the  ship  before  leaving  the 
port,  to  make   certain   that  all   infected   Stegomyia  are  killed. 


46  HISTORY  OF  YELLOW  FEVER  ON  SHIPS 

Experience  shows  that  neglect  of  this  rule  invariably  sooner  or 
later  leads  to  the  spread  of  yellow  fever.  I  know  of  one 
instance  where  a  Central  American  ship  was  fumigated,  with 
the  exception  of  the  engine-room  :  the  consequence  was  that 
yellow  fever  developed  on  board  when  the  port  of  arrival  was 
reached. 

Railway  carriages  may  also  transport  infected  Stegomyia. 
It  is  well  known  how  outbreaks  of  yellow  fever  are  liable  to 
spread  to  the  towns  along  a  railway  line.  Therefore  if  it  is  not 
possible  to  keep  the  carriages  outside  an  infected  town,  they 
should  be  fumigated  before  starting  on  their  journey. 

Cargoes  and  passengers'  baggage  may  harbour  mosquitos. 
The  danger  is  not  great,  but  instances  have  been  met  with, 
so  that  there  is  just  a  possibility.  Much,  however,  will  depend 
upon  the  nature  of  the  merchandise  and  where  it  was  packed, 
for  it  stands  to  reason  that  it  is  not  easy  to  entrap  a  Stegomyia 
in  a  bale  of  goods. 

Lighters. — For  Stegomyia  in  lighters,  see  under  "  Trade  Routes 
and  Yellow  Fever." 

References 

Gillkrest  (J.)— "On  Yellow  Fever  in  Ships"  {Second  Report  on 
Quarantine)^  London,  1852. 

FORGET  (C.  P.) — Medicine  Navale,  vol.  x.,  Paris,  1832. 

CHANTEMESSE  ET  BOREL  (F.) — Moustiques  etjievrejaune,  Paris  1905. 

Boyce  (Sir  R.  W.) — Health  Progress  and  Administration  in  the  West 
Indies,  London,  19 10;  Report  on  Yellow  Fever,  British  Honduras, 
1906. 

Souchon  (F.) — "Fruit  Vessels,  Mosquitos  and  Yellow  Fever,"  Journal 
American  Medical  Association,  1903. 

Graham  (E.) — "Fruit  Vessels,  Mosquitos  and  Yellow  Fever,"  Journal 
American  Medical  Association,  1908. 

Carter  (H.  R.) — "  Shipment  of  Merchandise  from  a  Town  infected  with 
Yellow  Fever,"  Report  Marine  Hospital  Service,  Washington,  1899  ; 
"Train  Inspection  in  Yellow  Fever  Epidemics,"  Atmual  Report 
Marine  Hospital  Service,  Washington,  1898;  "The  Methods  of  the 
Conveyance  of  Yellow  Fever  Infection,"  Yellow  Fever  Institute 
Bulletin,  No.  10,  1902  ;  "Yellow  Fever  in  France,  Italy,  Great 
Britain,  and  Austria,"  and  "  Bibliography  of  Yellow  Fever  in  Europe," 
Yellow  Fever  Institute  Bulletin,  No.  8,  1902. 


STEGOMYIA  ON  SHIPS  47 

GRUBBS  (S.  B.) — Bulletin,  Yellow  Fever  Institute,  1903. 

Gudden — "  Gelbfiebermticken  an    Bord,"   Archiv.  fiir  Schiffs   u.    Tropen 

Hygiene,  Band  ix.  7,  1905. 
DUPREZ  (J.) — "Mostiques  et  Navires,"  Revue  dhygiene,  March  1904. 
Manning  (C.  J.) — "  Notes  on  Yellow  Fever  "  {Paper  read  before  the  Barbados 

British  Med.  Association,  24th  February  1909). 
Pym  (Sir  W.) — Observations  on  Bulam  or  Yellow  Fever,  London,  1848. 
"  Persistence    of   Yellow   Fever    Infection   on   Shipboard,"  Med.    Record, 

New  York,  September  1901. 
Durham   (H.  E.) — "Report   of  the   Yellow  Fever  Expedition   to   Para," 

Liverpool  School  Trop.  Med.,  1902. 


CHAPTER  VII 

HISTORY  OF  YELLOW  FEVER  ON    THE  WEST  COAST   OF  AFRICA  * 

General.  Yellow  Fever  in  Sierra  Leone.  Yellow  Fever  in  Southern 
Nigeria.  Yellow  Fever  on  the  Gold  Coast.  Yellow  Fever  in  the 
Gambia.  Yellow  Fever  in  Senegal.  Yellow  Fever  in  Dahomey. 
Yellow  Fever  in  Togoland.     Yellow  Fever  in  Ascension  and  Boa  Vista. 

General 

The  conclusion  arrived  at  concerning  the  question  whether 
yellow  fever  was  first  endemic  in  the  West  Indies  or  in  Central 
and  Southern  America,  was  that  yellow  fever  was  endemic 
amongst  the  early  inhabitants  of  both  places.  When  the  even 
more  fragmentary  history  of  yellow  fever  in  West  Africa  is 
examined,  we  will,  I  think,  come  to  a  similar  conclusion  as 
regards  the  West  African  continent,  viz.,  that  yellow  fever  was 
in  all  probability  a  disease  endemial  to  the  native  races  of  the 
coast.  West  Africa  did  not  attract  military,  or  missionary,  or 
even  commercial  expeditions  at  so  early  a  date  as  did  the  more 
attractive  New  World.  It  is  not  until  the  eighteenth  century 
that  information  begins  to  filter  home  of  the  deadly  African 
fevers  of  the  coast,  of  "  Bulam  fever"  (1793),  of  the  "fever  of 
Fernando  Po,"  of  the  "fever  of  the  Bight  of  Benin,"  etc. 
Amongst  the  earliest  records  are  those  relating  to  the  presence 
of  yellow  fever  in  St  Louis  in  1778. 

The  fact  that  yellow  fever  has  persisted  in  unbroken  line 
from  the  eighteenth  century  to  the  present  day  appears  to  me 
to    be   the   strongest   evidence    in   favour    of    the    essentially 

1  Reprinted  by  kind  permission  from  the  British  Medical  Journal,  191 1. 

4S 


A.  JX  D 


Bale.  iDajuelsscnJ^lUh. 


Bale  a  Dojuclssox  J.'d hib 


EARLY  HISTORY  49 

endemial  character  of  the  disease.     Also  many  of  the  earlier 
military  writers  on  yellow  fever  adopted  this  view. 

In  the  case  of  the  sister  disease,  malaria,  we  do  not  discuss 
whether  it  was  imported  into  West  Africa  or  whether  it  was 
endemic.  We  regard  it  as  a  disease  essentially  endemic  to 
those  peoples  living  amongst  Anophelines ;  similarly,  having 
regard  to  the  very  widespread  distribution  of  the  Stegomyia  in 
Africa,  we  may  reasonably  assume  that  yellow  fever  has  existed 
so  long,  that  it  may  reasonably  be  regarded  as  endemic.  As  in 
the  case  of  malaria  so  in  yellow  fever  the  infection  may,  of 
course,  have  been  introduced,  but  introduced  at  such  an  early 
period  that  the  question  whether  imported  or  endemic  is  beside 
the  mark.  We  know  that  there  still  are  countries,  as  the  East 
Indies,  in  which  the  Stegomyia  abounds,  but  in  which  the  disease 
has  so  far  not  been  signalled. 

We  also  know  that  in  the  eighteenth  century  ships  could 
have  readily  at  any  time  introduced  the  disease  into  West 
Africa,  for  in  those  days  the  ships  were  exceedingly  few  which 
did  not  regularly  carry  infected  Stegomyia  and  patients  suffering 
from  the  fever.  The  tables  were  turned  when  Grenada  accused 
Bulam,  in  West  Africa,  for  having  introduced  the  nova  pestis, 
as  they  termed  it,  into  the  West  Indies. 

The  story  is  instructive,  because  it  shows  that  at  that  period 
great  confusion  had  already  arisen  as  to  whether  yellow  fever 
was  contagious  or  not ;  this  same  confusion  has  persisted  to  the 
present  period  in  West  Africa.  Dr  Chisholm  maintained  that 
up  to  1793  yellow  fever  was  a  miasm  fever,  and,  therefore, 
non-contagious  ;  but  that  in  that  year  the  ship  Hankey  introduced 
"  a  new  plague,"  as  he  called  it,  into  Grenada  for  the  first  time, 
from  whence  it  spread  to  the  other  islands,  and  from  them  to 
America  and  Europe. 

In  the  eighteenth  century  the  slave-ship  was  no  doubt  one 
of  the  most  powerful  factors  in  the  distribution,  not  only  of 
yellow  fever  but  of  all  other  racial  and  endemic  diseases  and 
of  the  insect  carriers  peculiar  to  them.     Not  only  did  the  slave- 

D 


50  YELLOW  FEVER  IN  WEST  AFRICA 

ship  carry  human  beings  in  whose  blood  might  have  been  the 
virus  of  yellow  fever,  malaria,  sleeping  sickness,  relapsing  fever, 
filariasis,  plague,  etc. — it  equally  well  served  as  the  means  of 
transport  of  the  various  species  of  mosquito,  fly,  or  flea.  Some 
of  these  might  have  been  taken  on  board  infected  ;  others  we 
know  could  have  developed  on  board  ship ;  for,  in  all  probability, 
every  cask  of  water  taken  on  board  at  a  tropical  station  was 
already  infected  with  the  ova  or  larvae  of  the  Stegomyia.  The 
"  slaver "  was  a  floating  native  village,  in  which  the  worst 
features  of  the  native  village  were  reproduced,  white  and  blacks 
living  jammed  together  in  hot  stifling  quarters,  providing  the  ideal 
conditions  for  the  multiplication  of  the  Stegomyia  and  the 
spread  of  yellow  fever.  The  slave-ship  justly  earned  its  reputa- 
tion of  being  the  great  cause  of  the  dissemination  of  diseases, 
and  now  in  the  light  of  modern  discoveries  we  more  strongly 
than  ever  realise  the  truth  of  this  statement. 

The  consideration  of  the  following  records  of  outbreaks  of 
yellow  fever  in  West  Africa  shows  how  often  history  repeats 
itself.  If  the  early  settlements  in  the  West  Indies  and  in 
Central  America  were  hampered  by  yellow  fever,  so,  precisely, 
on  the  West  Coast  of  Africa,  the  foundation  of  missionary 
settlements,  or  the  arrival  of  new  regiments  were  heralded  as  a 
matter  of  course  by  outbreaks  of  what  in  every  probability  was  the 
same  disease. 

References 

Chisholm  (Dr)   and  Gillkrest   (Dr)  —  Second  Report   on    Quarantine 

Yellow  Fever,  London,  1852. 
STORMONT   (Charles) — Essai    sur    la   typographie   medicate  de    la    cote 

occidentale  de  VAfrique  et  particulierement  sur  celle  de  la  colonic  de 

Sierra  Leone,  1882. 
Boyle  (James) — Medico-historical  Account  of  the  Coast  of  Africa,  London, 

1831. 
HORTON  (J.  A.  B.) — The  Diseases  of  Tropical  Climates  and  their  Treatment, 

Edinburgh,  1874. 
Quarterly  Medical  Reports  of  Troops  serving  on  the  West  Coast  of  Africa. 
Report  by  Colonel  Ord  upon  the  Condition  of  the  British  Settlements  on  the 

West  Coast  of  Africa,  1865. 


SIERRA  LEONE  51 

Berenger-Feraud  (L.  J.  BJ—Traite' de  lafievre  jaune,  Paris,  1890. 
Veitch  (James)— A  Letter  to  the  Commissioners  for  Transports  on  Yellow 

Fever,  London,  1818. 
Beaver  (Captain  Philip) — African  Memoranda :  Settlement  on  the  Island 

of  Bulama,  London,  1805. 

History  of  Yellow  Fever  in  Sierra  Leone 

The  foundation  and  settlement  of  Freetown  appears  from 
the  commencement  to  have  been  impeded  by  outbreaks  of 
yellow  fever.  References  are  constantly  made  by  writers  on 
yellow  fever  to  an  epidemic  which  occurred  in  181 5.  According 
to  Johnson,  in  that  epidemic  26  out  of  50  died,  the  symptoms 
being  jaundice,  pains  in  the  loins,  stupidity  in  the  head,  black 
discharge  or  black  vomit,  followed  soon  by  death,  He  states 
further  that  the  Nova  Scotia  settlers  called  it  break  bone  fever. 
The  fever  was  at  the  time  attributed  to  a  vessel  which  arrived 
in  January  18 15.  There  can  be  little  doubt  that  the  disease 
was  genuine  yellow  fever. 

This  epidemic  is  also  referred  to  by  Staff-surgeons  Barry 
and  Fergusson. 

French  writers  have  taken  it  for  granted  that  Sierra  Leone 
was  the  home  of  yellow  fever  on  the  West  Coast,  on  the  very 
natural  ground  that  it  was  more  thickly  peopled  and  had  wider 
relations  with  the  outside  world. 

Pym  also  contended  that  Sierra  Leone  was  the  home  of 
yellow  fever  in  West  Africa. 

Griesinger  believed  that  it  had  early  become  endemic. 

From  Freetown  the  disease  is  supposed  to  have  spread  to 
the  other  parts  of  the  coast. 

1817. — Johnson  refers  to  this  year  as  an  epidemic  year,  and 
states  that  3  missionaries  died  after  five  days'  illness. 

In  1 82 1  a  missionary  died  from  yellow  fever  accompanied 
by  black  vomit. 

From  1822  to  1824  a  considerable  number  of  cases  occurred. 
Staff-surgeon  Barry,  who  described  the  outbreak,  states  that  it 
broke  out  in  December  1822;  and  that  the  first  case  was  that 


52 


YELLOW  FEVER  IN  WEST  AFRICA 


of  a  sailor ;  previously,  however,  the  crews  of  several  ships  in 
the  harbour  had  been  attacked  with  what  he  describes  as  the 
endemial  remittent  fever  of  the  locality.  It  was  also  a  matter 
of  much  speculation,  whether  the  disease  was  imported  or 
endemic  ;  some  held  that  it  was  an  imported  contagious  disease, 
others  that  it  was  local  in  origin,  and  that  the  endemial  remittent 
fever  of  the  place  was  another  form  of  the  disease  ;  others,  again, 
held  that  the  endemial  remittent  and  yellow  fever  had  a  common 
parent.  One  thing  is  clear,  however,  from  the  description  of 
the  symptoms  and  post-mortem  appearance :  that  the  disease  was 
yellow  fever. 

The  white  population,  and  especially  the  sailors,  suffered 
from  the  disease  ;  out  of  a  party  of  12  schoolmasters,  with  their 
wives,  10  died. 

It  was  noticed,  however,  that  the  blacks  remained  healthy, 
with  the  exception  of  the  Croomen.  During  the  outbreak  the 
H.M.S.  Bann  arrived  and  her  crew  were  attacked.  She  then 
sailed  for  Ascension,  and,  some  affirm,  introduced  the  disease  for 
the  first  time  into  that  island  in  1823.     (See  Ascension  Island.) 

The  mortality  is  given  as  follows  : — 
(Walker)— 

Deaths. 

7 
2 

9 
II 

12 
24 
12 

77 


December 

1822 

January 

1823 

February 

5) 

March 

J) 

April 

J) 

May 

5} 

June 

» 

Total 

According  to  Burnett,  a  disease  differing  from  the  usual 
remittent  and  possessing  the  character  of  yellow  fever  occurred 
in  1823.  It  was  not  contagious  and  was  not  imported  by  the 
H.M.S.  Caroline. 

In  1825  an  epidemic  is  described,  with  a  total  mortality  of 
263. 


SIERRA  LEONE  53 

There  was  also  a  considerable  outbreak  in  1826,  for  out  of  a 
garrison  of  535  soldiers,  115  died  from  14th  June  to  24th 
August. 

Major  Crofts  gives  a  table  showing  the  mortality  from 
remittent  fever  in  July  1826.  Fifty-three  men  and  3  officers 
are  stated  to'  have  died.  In  all  probability  the  disease  was 
yellow  fever. 

In  1827  a  typical  case  of  black  vomit  was  recorded 
(Fergusson). 

In  1829  an  epidemic  broke  out,  and  in  the  garrison  of  130 
whites  12  cases  were  reported.     Eleven  deaths  occurred. 

Boyle,  in  commenting  upon  the  1829  outbreak  in  Freetown, 
and  refuting  the  idea  that  the  fever  was  imported  into  Freetown 
by  the  H.M.S.  Eden,  states  that  occasional  cases  of  yellow  fever 
were  met  with  every  year  in  Freetown.  Violent  controversy 
also  arose  as  to  whether  the  disease  was  contagious  or  not.  In 
consequence,  a  memorandum  to  the  effect  that  yellow  fever 
was  not  contagious,  was  drawn  up  in  Freetown  on  27th 
May  1829,  and  signed  by  J.  Boyle  (Colonial  Surgeon),  M. 
Sweeny,  M.D.,  Deputy  Inspector,  and  W.  Fergusson,  Surgeon, 
R.A.M.C. 

In  1835  a  case  of  black  vomit  is  recorded. 
The  origin  of  the  outbreak  was  ascribed  to  importation  from 
Fernando  Po,  and  by  others  to  the  town  of  Sangara,  400  miles 
distant.  It  was  seriously  proposed  to  build  a  high  wall  to  keep 
out  the  pestilential  breeze  which,  it  was  alleged,  came  from  this 
town. 

The  next  large  epidemic  occurred  in  the  years  1836- 1838.  In 
December  1836,  a  malignant  fever  broke  out  amongst  the 
crew  of  the  barque  Mary  whilst  in  Freetown  ;  1 5  of  the  crew 
were  attacked  and  5  died.  Cases  then  appeared  on  shore  ;  one  of 
those  who  died  being  a  mulatto  lady  who  had  come  from  the 
United  States  ;  another  was  that  of  a  young  man  who  had 
only  been  one  month  in  the  colony.  Five  of  the  crew  of 
another  ship,  The  Lady  Douglas,  who  had  gone  ashore  and  who 


54 


YELLOW  FEVER  IN  WEST  AFRICA 


had  lodged  in  the  house  previously  occupied  by  the  crew  of  the 
Mary  were  infected,  and  4  died  in  January  1837. 

Deaths  occurred  in  March  and  April,  and  the  fever  was  at  its 
height  in  May  and  June.  The  last  case  was  recorded  in  July, 
when,  as  the  writer  states,  the  yellow  fever  was  succeeded  by  the 
common  remittent  fever  of  Freetown,  and  confidence  was  once 
more  restored ;  but,  adds  the  writer,  to  everyone's  astonishment 
the  fever  broke  out  afresh  before  the  end  of  the  year.  The 
first  to  succumb  were  the  crews  of  three  ships  which  had  arrived 
during  the  autumn,  and  Staff-surgeon  Fergusson  attended  20 
cases  amongst  the  white  residents  between  November  1 837  and 
February  1838  ;  2  ended  fatally. 

In  1839,  6  officers  of  the  garrison,  7  officers  of  the  royal 
navy,  and  many  soldiers  and  sailors  died  of  yellow  fever. 


Table  showing  the  number  of  cases  treated  by  Fergusson 
from  February  1837  to  March  1838. 


Occupation. 


Navy 

Army         .         ...... 

European  resident  merchants  and  seamen 

Total 


Cases. 

Deaths. 

43 
11 

272 

25 

,5 
107 

326 

137 

During  the  prevalence  of  the  epidemic,  H.M.S.  Curlew 
arrived  and  stayed  one  week  in  Freetown  harbour  and  sailed  for 
the  Gambia.  During  her  voyage  the  crew  are  stated  to  have 
suffered  from  an  outbreak  of  the  disease.  Freetown  was,  in 
consequence,  blamed  for  having  introduced  yellow  fever  into 
that  colony  for  the  first  time. 

As  in  the  previous  epidemic,  so  also  in  this  one  the  relation- 
ship of  the  endemial  remittent  fever  to  yellow  fever  was  much 
discussed.  Fergusson  put  forward  the  opinion  that  yellow  fever 
or  malignant  remittent  fever  was  only  the  malignant  form  of 
the  common  "  endemial  remittent "  fever,  and  he  thought  that 


SIERRA  LEONE  55 

if  cases  of  the  simple  endemial  remittent  type  were  transported 
by  ship  to  other  localities  they  might  give  rise  to  the  malignant 
form.  Fergusson  firmly  believed  that  "yellow  fever  was  a 
product  of  the  colony  itself,"  but  that  both  the  Gambia  and 
Ascension  were  infected  from  Sierra  Leone. 

In  1837  Burton  described  an  outbreak  of  yellow  fever  in  the 
Island  of  St  Mary,  in  the  Gambia,  and  to  the  north-west  of 
Sierra  Leone. 

From  1837  to  1839  inclusive,  the  quarterly  medical  reports  of 
the  garrison  and  town  show  unquestionably  fatal  cases  of  yellow 
fever  entered  under  the  heading  of  malignant  remittent  fever. 

In  the  period  1840- 1845  there  is  a  yearly  record  of  the 
"  endemial  remittent  fever,"  sometimes  with  severe  and  fatal 
symptoms.     Ships'  crews  were  often  severely  affected. 

In  1845  a  case  of  malignant  remittent  or  yellow  fever 
appeared  ;  the  fever  broke  out  amongst  the  crews  of  the 
squadron  at  anchor  on  the  Roquelle  River. 

The'symptoms  recorded  are  unmistakable,  and  are  confirmed 
by  the  post-mortem  accounts  (Fergusson). 

In  this  year  also  there  appears  some  evidence  that  Bona 
Vista  was  infected  from  Freetown  by  H.M.S.  Eclair. 

It  is  also  stated  that  in  this  year  cases  occurred  frequently, 
and  with  the  most  severe  symptoms  amongst  the  newly  arrived 
sailors,  and  least  so  amongst  the  native  soldiers. 

At  this  period  also  the  expression  "bilious  remittent  fever  of 
the  country  "  and  "inflammatory  fever  "occurs — another  name 
no  doubt  for  the  same  disease. 

In  1847  an  epidemic  is  chronicled  by  Staff-surgeon  Lawson. 
The  resident  white  civilian  population  is  put  down  at  100,  and 
of  these  12  died  from  yellow  fever.  There  were  also  cases 
amongst  the  sailors  in  the  port  and  on  H.M.S.  Syren,  on  which 
ship  there  were  17  cases,  3  of  which  developed  black  vomit  ten 
days  after  embarkation. 

In  1850  a  case  of  fatal  yellow  fever  was  reported;  it  was 
said  to  have  been  introduced  by  a  sailing-ship  from  Rio. 


56  YELLOW  FEVER  IN  WEST  AFRICA 

In  1859  an  epidemic  occurred  in  which  100  whites  died  of 
the  disease. 

In  1865  and  1866  cases  were  also  observed. 

After  this  period  there  is  a  lull,  in  which  no  doubt  the 
disease  persists  amongst  the  permanent  residents,  but  in  a  mild 
and  undiagnosed  form,  but  does  not  make  itself  obviously- 
manifest,  owing  to  altered  conditions  in  the  navy,  mercantile 
marine,  and  in  commercial  enterprise. 

In  1S72  it  broke  out  again,  and  6  deaths  were  recorded.  The 
colonial  surgeon,  writing  in  1883,  states  we  have  had  no  cases 
of  yellow  fever  since  1872.  It  is  presumed  to  have  been  present 
in  1878.  In  1884  a  severe  epidemic  prevailed  in  Freetown;  the 
cases  appear  to  have  been  diagnosed  either  as  yellow  fever, 
severe,  or  pernicious  remittent  fever,  and  African  fever,  and  a 
dispute  arose  as  to  the  nature  of  the  fever. 

In  the  annual  military  returns  1  soldier  is  returned  as  having 
died  of  yellow  fever,  and  the  statement  is  made  under  date  25th 
June  1884,  that  yellow  fever  and  a  severe  type  of  remittent  fever 
prevailed  in  the  town  during  this  year. 

There  is  no  doubt  that  great  confusion  existed  at  the  time 
between  remittent  fever  and  yellow  fever. 

The  term  "  bilious  remittent  fever"  has  been  employed  in  a 
great  number  of  cases  as  another  name  for  genuine  yellow 
fever ;  some  have,  however,  regarded  it  as  a  distinct  disease. 
From  the  history  of  yellow  fever  on  the  West  Coast,  it  certainly 
appears  probable  that  a  very  large  proportion  of  the  bilious 
remittent  fevers  were  cases  of  yellow  fever.  When  the  fever 
assumed  a  more  severe  type  and  became  epidemic  it  was  called 
yellow  fever  ;  as  long  as  the  cases  remained  mild  they  were  put 
down  as  remittent  fever. 

The  question,  therefore,  arises :  Do  the  remittent  fevers 
represent  the  mild  forms  of  yellow  fever?  In  this  connection  it 
is  interesting  to  note  that  there  is  some  evidence  from  the  MS. 
notes  of  the  period,  that  the  "  endemial  remittent  fever  of 
Freetown"   conferred    a   certain   degree    of  immunity   against 


1884  EPIDEMIC  57 

yellow  fever,  which  would  show  that  the  remittent  fever  might 
be  a  mild  form  of  yellow  fever.  Moreover,  the  fact  that  the 
natives  escaped  the  severer  form  would  also  tend  to  show  that 
they  had  had  a  milder  form  of  the  disease,  probably  the 
"  endemial  remittent."  Lawson  states  that  some  medical  men 
of  the  period  considered  that  the  natives  did  suffer  from  a  mild 
form  which  was  capable  of  inducing  the  malignant  form  in  the 
whites.  Lawson  himself  considered  that  both  diseases  had  a 
common  origin. 

A  Dr  Davies,  practising  in  Freetown,  reported  a  case  of 
yellow  fever  on  15th  July  1884.  Upon  receipt  of  this  report, 
the  acting  principal  medical  officer  sent  a  letter  to  Dr  Davies, 
asking  him  upon  what  grounds  he  had  diagnosed  a  case  of 
yellow  fever,  and  if  "  he  considered  the  cases  of  yellow  fever, 
which  he  had  had  in  his  practice,  to  be  contagious  or  not  ?  " 
In  a  subsequent  letter  to  the  Governor,  the  principal  medical 
officer  stated  that  in  his  opinion  Dr  Davies  had  made  a 
grievous  mistake  in  his  diagnosis  of  yellow  fever.  This 
correspondence  is  of  great  interest,  as  showing  the  attitude  of 
mind  at  the  time  as  regards  the  nature  and  diagnosis  of  yellow 
fever.  Yellow  fever  in  the  same  year  appears  to  have  broken 
out  at  Rufisque  in  another  part  of  the  colony. 

In  1884  the  evidence  shows  that  there  was  considerable 
reluctance  to  notify  the  outbreak  as  yellow  fever,  and  cases 
which  terminated  fatally  and  with  the  classical  symptoms  of 
black  vomit  were  entered  as  "pernicious  remittent  fever," 
"  African  fever,"  "  typhoid,"  and  "enteric  fever."  The  year  1884 
showed  a  mortality  of  50  amongst  the  whites ;  probably  the 
majority  of  these  were  yellow  fever. 

In  a  report  sent  on  30th  July  1884,  to  the  then  Secretary  of 
State — the  Earl  of  Derby — by  Sir  Arthur  Havelock,  the 
Governor  of  Sierra  Leone,  it  is  stated  that  a  fever  described  as 
typho-malarial  fever  was  prevalent  during  the  months  of  May 
and  June ;  recently  arrived  Europeans  suffered  most  severely. 
The  malignant  symptoms  of  the  disease  became  more  marked 


58  YELLOW  FEVER  IN  WEST  AFRICA 

every  day.  On  27th  June  the  disease  was  described  as  a 
"  pernicious  remittent  fever  on  the  borderland  of  yellow  fever." 
At  the  same  time  a  private  practitioner  had  already  concluded 
that  the  disease  was  yellow  fever,  and  the  military  medical 
officer  had  actually  reported  a  case  of  yellow  fever.  On  2nd 
June  a  European  died  of  black  vomit.  On  28th  July  2 
Europeans  died  of  yellow  fever,  diagnosed  as  such  by  the 
colonial  surgeon.  On  6th  July  another  fatal  case  occurred. 
After  this  date  a  few  more  cases  occurred,  but  of  a  less  virulent 
type. 

The  final  opinion,  given  on  the  17th  July  by  the  colonial 
surgeon  and  the  other  practitioners  in  Freetown,  was  that  the 
disease  was  a  "  mild  type  of  yellow  fever  of  a  non-contagious 
nature."  The  Governor  in  his  report  states  that  a  noticeable 
feature  was  that  as  the  disease  assumed  a  more  virulent  type,  it 
became  more  and  more  restricted  to  Europeans.  The  natives 
seemed  to  have  complete  immunity  from  its  attacks,  there  not 
being  a  single  authenticated  case  amongst  the  negro  population. 

To  Sir  Arthur  Havelock's  covering  despatch  is  appended  the 
report  of  the  special  medical  committee,  consisting  of  the 
acting  colonial  surgeon,  the  senior  military  medical  officer,  and 
Dr  Cole,  a  private  practitioner. 

From  the  report  it  appears  that  the  epidemic  was  most 
fatal  in  Westmoreland,  Rawdon,  and  Home  Streets  (the 
European  quarter).  The  disease,  they  state,  "  resembled  yellow 
fever  or  that  type  of  pernicious  remittent  fever  of  a  malignant 
destructive  type,  having  as  its  characteristics  yellowness  of  the 
skin  and  conjunctivae,  dark-coloured  and  very  offensive  alvine 
evacuations ;  dark-coloured  urine  containing  blood  casts  and 
very  obvious  albumin,  a  quick  pulse,  and  a  persisting  high 
temperature  ranging  from  i02°to  1050 ;  vomiting  often  persistent 
and  very  difficult  to  control,  dark  in  colour,  and  containing  a 
large  quantity  of  bile,  in  some  cases  with  distinctly  black 
vomit." 

Duration,  5-7  days ;  and,  in  malignant  cases,  4-5  days. 


FREETOWN  EPIDEMICS  59 

The  report  describes  the  types  of  fever  prevalent  on  the 
coast  as  intermittent  fever  or  ague,  remittent  fever,  enteric 
or  typho-malarial  fever,  and  pernicious  malignant  or  yellow 
fever. 

They  state  that  the  years  1 807, 1 809, 1812,1815,  and  1 8 1 9  were 
marked  by  great  sickness,  the  nature  of  which  they  do  not  state. 
They  allude  to  the  1823  yellow  fever  epidemic,  and  state  that 
in  1825,  out  of  902  persons  attacked  263  died.  Another 
epidemic  occurred  in  1829,  when,  out  of  150  Europeans  attacked 
11  died. 

In  1837  an  outbreak  also  occurred  in  April,  preceded  by  very 
suspicious  cases  in  January.  The  epidemic,  they  state,  died 
down,  passing  insensibly  into  the  common  endemic  remittent 
fever.  In  1838  yellow  fever  appeared  in  February  and  ended  in 
March. 

In  1839,  6  officers  died  of  yellow  fever  and  an  appalling 
number  of  the  troops;  7  officers  of  the  royal  navy  and  13 
seamen  died. 

In  1845  yellow  fever  broke  out  amongst  the  crew  of  Her 
Majesty's  squadron  at  anchor  in  the  Roquelle  River. 

In  1847  yellow  fever  was  epidemic  in  Freetown  during  June, 
July,  and  August. 

In  1859  also  an  epidemic  broke  out,  when  100  Europeans 
died  of  yellow  fever.     Cases  also  occurred  in  1865  and  1866. 

In  1872  there  was  an  epidemic,  and  6  deaths  occurred  in 
December  of  yellow  fever.  The  total  mortality  from  this  disease 
may  have  been  250. 

Dr  Lamprey,  describing  the  cases  of  yellow  fever  in  the  1884 
epidemic  in  the  British  Medical  Journal,  1885,  states  that  the 
outbreak  of  yellow  fever  in  Sierra  Leone  was  sporadic  in  origin, 
the  undoubted  product  of  Freetown,  and  that  all  attempts  to 
trace  its  origin  to  a  non-sporadic  source  had  failed. 

He  notes  the  difficulty  of  distinguishing  between  the  bilious 
remittent  fever  and  yellow  fever.  He  states  that  in  1853  yellow 
fever  was  present,  and  that  an  epidemic  occurred  in  1825.     He 


60  YELLOW  FEVER  IN  WEST  AFRICA 

states  that  also  in  the  years  1829,  1837,  1838,  1839,  1845,  1865, 
1 866,  and  1872  there  were  very  many  cases  of  yellow  fever. 

In  the  1884  epidemic  he  notes  that  the  total  death-rate 
amongst  the  native  population  was  35  per  1000;  and  amongst 
the  Europeans  6  per  cent,  per  month.  The  epidemic  com- 
menced in  May  and  lasted  until  August. 

He  then  describes  in  detail  the  symptoms  of  a  large  number 
of  cases.  There  can  be  no  doubt,  therefore,  that  there  existed  a 
severe  yellow  fever  epidemic  in  1884. 

Examination  this  year,  1910,  of  the  scanty  medical  reports 
of  Freetown  shows  that  in  the  year  1893- 1894  deaths  occurred 
from  pernicious  malarial  fever. 

In  1894  the  statement  is  made  that  there  were  16  deaths 
amongst  the  Europeans,  of  which  13  were  stated  to  be  due  to 
bilious  remittent  haemorrhagic  fever  and  1  from  malignant 
malarial  fever.  Three  of  the  cases  died  within  thirty-six  hours 
of  their  landing  from  the  rivers. 

Of  course  it  is  not  now  possible  to  be  certain  whether  they 
were  cases  of  blackwater  fever,  or  whether  some  of  them  were 
not  genuine  yellow  fever  cases. 

In  1899  there  were  17  cases  of  remittent  and  6  cases  of 
bilious  remittent  fever  entered  in  the  hospital  records. 

In  1900  the  statement  is  made  in  the  annual  report  that 
there  were  2  cases  of  yellow  fever  in  the  six  years  from  1885 
to  1 89 1. 

In  1908  a  Syrian  died  with  symptoms,  which  the  medical 
officer  who  was  in  attendance  regarded  at  the  time  as  a  case  of 
gastric  ulcer.  He  now  thinks  that  it  might  very  well  have  been 
a  case  of  yellow  fever. 

In  1909  a  fatal  case  also  occurred  which,  in  the  light  of 
recent  experience,  the  medical  officers,  who  were  in  attendance, 
now  conclude  was  yellow  fever. 

In  1910  some  10  cases  of  yellow  fever  have  been  reported, 
of  which  8  proved  fatal ;  but  there  may  have  been  more  cases 
and  more  deaths.     The  one  fact  which  is  certain  is  that  the 


PROOFS  OF  ENDEMIC  NATURE  61 

disease  was  yellow  fever,  and  that  the  Syrians  were  the  first 
attacked,  and  amongst  whom  the  greatest  mortality  occurred. 
The  outbreak  occurred  in  May  and  continued  into  September. 

From  the  preceding  history  of  epidemic  and  endemic  disease 
in  Freetown,  the  reader  is,  in  my  opinion,  forced  to  but  one 
conclusion,  that,  in  the  case  of  Freetown,  as  in  the  case  of  the 
towns  in  Central  America,  South  America,  and  the  West  Indies, 
yellow  fever  in  a  mild  or  virulent  form  has  been  a  disease 
common  amongst  those  living  in  the  Stegomyz'a-mfected  town  of 
Freetown  since  its  foundation  to  the  present  day. 

In  the  preceding  account  yellow  fever  is  diagnosed  and 
carefully  described  by  well-known  military  and  naval  surgeons, 
fully  conversant  with  the  disease  in  other  parts  of  the  world,  and 
the  descriptions  which  they  have  left  in  manuscript  prove  that 
their  diagnosis  was  correct. 

Again,  there  is  the  history  of  the  almost  annual  occurrence 
of  outbreaks  of  black  vomit — a  disease  which  all  observers 
mention  attacked  newcomers  in  preference  to  the  indigenous 
inhabitants.  Indeed,  authorities  were  agreed  that  the  perma- 
nent black  population  did  not  get  the  severe  yellow  fever  of  the 
white  man.  Some  authorities  began  to  discuss  the  relationship 
between  the  common  mild  endemial  remittent  fever,  or 
acclimatising  fever  of  Freetown  with  yellow  fever,  and  many 
concluded  that  the  mild  form  could  pass  into  the  severe  yellow 
fever.  Others  concluded  that  both  had  a  common  parent ; 
others,  again,  that  the  remittent  fever  of  the  native  could  give 
rise  to  the  yellow  fever  in  the  white  man. 

Another  authority  of  the  time  concluded  that  the  endemial 
remittent  fever  conferred  a  certain  degree  of  immunity  against 
yellow  fever.  All  these  are  points  which  have,  over  and  over 
again,  been  discussed  in  countries  where  yellow  fever  is  endemic. 
They  are  all  based  on  accurate  observation  ;  for,  no  doubt,  the 
mild  endemial  remittent  fever  of  the  inhabitants  of  Freetown  was 
in  very  many  instances  mild  yellow  fever,  and  it  naturally 
conferred  a  certain  degree  of  immunity,  or  perhaps   complete 


62  YELLOW  FEVER  IN  WEST  AFRICA 

immunity  to  a  subsequent  attack  of  yellow  fever.  Theendemial 
remittent  fever  of  the  native  was  a  source  from  which  the 
Stegomyia  obtained  its  infection.  The  outbreak  which  has 
taken  place  this  year,  and  in  which  the  Syrians  were  early 
infected  is,  in  my  opinion,  the  final  proof  of  the  essentially 
endemic  character  of  the  disease  in  Freetown.  The  Syrians  have, 
in  recent  years,  increased  in  numbers  in  Freetown.  They  are 
engaged  in  a  small  trade,  and  live  with  and  amongst  the  natives 
in  the  more  crowded  parts  of  Freetown.  Their  yards  and  those 
of  their  neighbours  were  infested  with  Stegomyia.  It  was  but 
natural,  therefore,  that  yellow  fever  should  first  manifest  itself 
amongst  them,  as  they  were  obviously  most  exposed  to  the 
infection.  On  the  other  hand,  the  merchants  and  officials  living 
in  better  and  less  congested  quarters  suffered  to  a  far  less  degree, 
whilst  those  completely  segregated  were  not  affected  at  all. 

Sir  William  Pym,  in  commenting  upon  the  origin  of  yellow 
fever  in  West  Africa,  states  the  great  difficulty  of  bringing 
positive  proof  of  its  existence  amongst  the  natives,  because  they 
have  it  in  so  mild  a  form  that  it  does  not  kill. 

He  mentions  how  the  Croomen  escaped  yellow  fever  in  the 
West  African  squadron,  when  the  white  crews  were  suffering  and 
dying  from  the  disease.  He  concludes  that  it  is  reasonable  to 
suppose  that  the  Croomen  had  already  had  the  disease  in  their 
native  country. 

Note. — The  opinion  of  the  acting  principal  medical  officer 
— Dr  Kennan — and  of  others  was,  that  the  epidemic  of  1910  had 
a  local  origin  and  was  not  imported. 

This  opinion  of  the  endemic  origin  of  the  epidemic  of  yellow 
fever  was  the  view  most  frequently  adopted  by  those  who  had 
been  called  upon  to  investigate  outbreaks  in  the  past.  Investi- 
gation failed  in  1910,  as  in  past  years,  to  prove  importation. 

I  concur,  as  the  result  of  examination  of  the  facts  on  the 
spot,  with  the  endemic  origin  of  this  outbreak. 

Taking  into  account  the  very;numerous  outbreaks  and  sporadic 
cases  of  yellow  fever  which  have  been  described  in  Sierra  Leone 


GAMBIA  63 

during  the  nineteenth  century  up  to  date,  and  bearing  in  mind 
that  after  no  epidemic  or  sporadic  case  was  any  town  fumigated 
to  destroy  the  infected  Stegomyia,  we  may  be  certain  that, 
following  the  laws  of  yellow  fever,  cases  of  the  disease  occurred 
in  intervening  years.  When  these  facts  are  borne  in  mind,  and 
the  same  reasoning  applied  to  the  other  colonies  in  West  Africa, 
we  are  in  possession  of  facts  which,  in  my  opinion,  place  it 
beyond  a  doubt  that  yellow  fever  is  endemic  on  the  west  coast 
of  Africa. 

References 

Harrison  Rankin  (F.) — The  White  Man's  Grave;  or,  A   Visit  to  Sierre 

Leone,  1836. 
Boyle  (J.) — Account  of  the  Western  Coast  of  Africa,  London,  1831. 
WALKENAER — Voyages  en  A frique,  Paris,  1842. 
B-RYSON  (Alexander) — Account  of  the  Origin,  Spread,  and  Decline  of  the 

Epidemic  Fevers  of  Sierra  Leone,  1 849. 
Johnson  (W.  A.  E.) — Memoirs  of  18 16-1823;   Church  Mission  in    West 

Africa,  1845  •,   One  Hundred  Years  of  the  C.M.S. 
Walker  (S.  A.) — The  Church  of  England  Mission  in  Sierra  Leone,  London, 

1847  ;    Quarterly   Medical  Reports  of  the  Troops  in  Sierra  Leone ; 

MS.  Reports  Preserved  in  Freetown;  Annual  Medical  Reports  of 

Freetown;  The  Medical  Letter  Book,  Freetown. 
HAVELOCK   (Sir  ARTHUR) — The  Report  of  the  Special  Committee  on  the 

Cause  of  the  Mortality  in  1884  in  Freetown,  Colonial  Office,  1884. 
Lamprey  (J.  J.) — "Outbreak  of  Yellow  Fever  in  Sierra  Leone,"  1884,  Brit. 

Med.  fourn.,  vol.  ii.,  1885. 
Horton  (J.  A.  B.) — The  Diseases  of  Tropical  Climates  and  their  Treatment, 

Edinburgh,  1874. 
Burton    (E.    J.) — "Observations   upon    the    Climate,    Topography,   and 

Diseases   of   the    British   Colonies   in  Africa,"  Provincial  Medical 

Journal,  vol.  i.,  1842. 

Yellow  Fever  in  the  Gambia 

It  is  most  probable  that  yellow  fever  appeared  in  the  Gambia 
at  the  same  period  as  in  the  case  of  Sierra  Leone  and  in 
Senegal,  for  epidemics  in  North- West  Africa  appear  to  have 
been  on  most  occasions  in  the  past  widespread,  sometimes 
starting  in  one  colony,  sometimes  in  another,  but  usually  ending 
by  affecting  all  three — Sierra  Leone,  the  Gambia,  and  Senegal. 


64  YELLOW  FEVER  IN  WEST  AFRICA 

The  period  embraced  by  these  epidemics  and  sporadic  cases 
extended  from  the  end  of  the  eighteenth  century,  through  the 
nineteenth,  up  to  the  present  epoch. 

Outbreaks  have  been  recorded  in  1768  and  1869,  1842,  1845, 
1852,  and  in  1878,  when  the  fever  is  stated  to  have  been  severe. 
During  this  period  it  will  be  remembered  that  the  ships  of  the 
mercantile  and  royal  navies  were  perpetually  infected  with 
yellow  fever,  and  that,  therefore,  the  disease  could  be  imported 
in  any  year  until  it  became  endemic.  Of  course  the  disease 
might  have  been  endemic  from  a  much  earlier  period,  but,  as 
colonisation  only  set  in  in  the  eighteenth  century,  it  is  im- 
possible to  know  what  happened  before  this  date,  for  here,  as 
elsewhere,  it  was  only  by  the  arrival  of  non-immunes  that  the 
world  was  made  aware  of  the  existence  of  the  disease. 

We  may  reasonably  suppose  that  the  Siegomyia  existed  in 
the  Gambia  in  early  times  just  as  it  does  to-day. 

In  1837  Fergusson  describes  an  outbreak  of  yellow  fever  in 
the  Gambia,  imported,  so  he  believes,  by  the  H.M.S.  Curlew, 
which  sailed  from  Freetown,  where  it  had  remained  one  week ; 
and  during  an  outbreak  members  of  the  crew  contracted  the 
disease,  and  when  the  ship  arrived  in  the  Gambia  the  sick  were 
taken  ashore  and  the  disease  spread  amongst  the  residents.  The 
colonial  surgeon  died  from  it.  In  the  same  year  yellow  fever 
was  present  in  Senegal. 

From  the  annual  report  of  the  West  African  station  it 
appears  that  4  cases  of  yellow  fever  occurred,  of  which  2 
proved  fatal,  in  the  garrison  in  the  period  1 841 -1842. 

In  1878  a  severe  epidemic  is  stated  to  have  occurred,  but, 
so  far,  I  have  been  unable  to  come  across  an  account  of  it.  It 
was  also  present  in  Senegal  in  this  year. 

In  June  1900,  a  fatal  case  of  yellow  fever  was  reported 
officially  from  the  Gambia.     It  was  present  in  Senegal. 

Bathurst  was  declared  an  infected  port  in  June  1901,  also 
Senegal. 


SENEGAL  65 

References 

Lidin  (C.) — "  Coup  d'ceil  sur  la  climatologie  et  pathologie   du  Senegal," 

Paris,  1882. 
Chichester    (C.   R.) — Annual   Medical  Reports    of  the    West   African 

Station. 

Yellow  Fever  in  Senegal 

The  history  of  yellow  fever  in  the  French  Colony  is  com- 
paratively very  complete,  numerous  French  authorities  of 
eminence  having  carefully  described  the  various  epidemics.  As  in 
the  case  of  Sierra  Leone,  so  in  this  colony  the  history  of  the  disease 
is  coincident  with  white  colonisation  and  commercial  advance. 

Outbreaks  of  sporadic  cases  are  recorded  in  1768,  1769, 
1778-1779,  1814,  1816,  1828,  1830,  1837,  1840,1841,  1845,  1846, 
1852,  1858,  1863,  1866-1867,  and  1872.  The  symptomatology  of 
very  many  of  the  outbreaks  has  been  carefully  recorded  by 
Berenger-Feraud,  so  that  there  is  no  doubt  about  the  nature  of 
the  disease. 

From  the  year  1830  yellow  fever,  however,  attracted  the 
attention  of  numerous  observers,  and,  as  in  the  case  of  the  other 
West  African  colonies,  the  symptomatology  is  given  with  care, 
so  that  here  again  there  is  no  doubt  about  the  true  nature  of  the 
disease.  Schotte,  in  describing  the  great  epidemic  of  1778-1779, 
states  that  59  whites  died ;  that  the  deaths  were  most  frequent 
amongst  the  whites,  next  in  frequency  amongst  the  mulattos, 
and  least  often  amongst  the  blacks.  The  symptoms  were : 
intense  headache  and  lumbar  pain  ;  congestion  of  the  eyes ; 
obstinate  vomiting  or  hiccough  ;  black  vomit  (coffee  ground-like 
material) ;  urine  greatly  diminished  or  total  suppression, 
delirium,  coma,  and  death.  Frequently  the  very  characteristic 
and  often  fatal  symptom  of  "  feeling  better "  occurred  towards 
the  termination  of  the  illness.  From  1778  to  18 14  no  large 
outbreak  occurred  ;  then  in  18 16  the  disease  broke  out  at  Cape 
Manuel.  From  181 7  to  1830  Schotte  considers  there  were 
numerous  sporadic  cases.  In  1830  a  widespread  epidemic 
occurred  which  affected  Goree,  Saint  Louis,  and  Dakar. 

e 


66  YELLOW  FEVER  IN  WEST  AFRICA 

In  1837  the  disease  again  broke  out  in  the  Island  of  Goree, 
introduced,  as  it  was  thought  by  some,  from  Bathurst.  Bathurst 
had  meanwhile  attributed  their  own  outbreak  to  infection  from 
Freetown  {see  Sierra  Leone). 

From  1837  to  1859  there  is  an  apparent  absence  of  recorded 
outbreaks.  Then  in  1858- 1859  the  disease  again  attracted 
attention.  Again  from  1864- 1867  there  are  records  of  small 
outbreaks. 

In  1872  a  severe  epidemic  occurred,  which  spread  from 
Goree  to  Saint  Louis,  and  then  to  Bakel  in  the  Upper 
Senegal. 

That  is  to  say,  the  disease  now  showed  its  characteristic 
tendency  to  penetrate  into  the  interior  from  the  coast,  following 
the  trade  routes.  The  writers  of  the  period  also  state  that  up 
to  this  date  yellow  fever  was  usually  regarded  as  imported  from 
Freetown  or  the  Gambia.  But  after  1872  authorities  were  dis- 
posed to  admit  its  endemic  origin. 

In  1878  an  outbreak  is  recorded,  and  it  was  stated  also  to  be 
present  in  1897. 

From  1900  to  1906  there  is  an  annual  record  of  cases.  In 
1900  quarantine  was  officially  declared,  and  Dakar,  Goree,  and 
Conakry  were  declared  infected  ports.  The  1 900- 1 901  outbreak 
has  been  made  the  subject  of  more  than  one  monograph. 
Kermorgant  states  that  there  were  146  cases  and  225  deaths, 
and  describes  how  it  spread  up  into  the  interior  and  along  the 
railroad  from  Kayes  to  Dioubeba  in.  the  Soudan.  Berenger- 
Feraud  has  also  written  the  history  of  the  epidemic.  Both 
authorities  mention  how  the  disease  was  considered  by  many 
as  endemic  in  Senegal.  The  possibility,  however,  of  the  ever- 
shifting  Syrians  having  introduced  the  disease  is  also  mentioned. 
In  1902  a  recrudescence  of  the  disease  is  recorded  in  the  Soudan 
and  Upper  Senegal.  In  1904  Dakar  is  declared  to  be  an 
infected  port.  In  1906  yellow  fever  breaks  out  at  Bamaku  in 
Upper  Senegal,  and  at  points  along  the  Kayes-Niger  railway. 
The  first  case  appeared  to  start  in  Segu  in  the  Soudan. 


SENEGAL  67 

An  official  communication  from  the  British  Consul-General 
in  Dakar  states  that  yellow  fever  was  present  in  1906  during 
the  months  of  September,  October,  and  November  in  the 
Upper  Senegal  and  Niger  Territories. 

Thus,  in  Senegal,  there  has  occurred  an  advance  of  yellow 
fever  from  the  coast  into  the  interior  following  the  railroad  and 
trade  routes.  This  same  phenomenon  has  repeatedly  occurred 
in  Central  America  (see  my  Honduranian  Report),  and  will 
be  repeated  in  Nigeria  and  in  the  Gold  Coast  colonies  unless 
preventive  measures  are  taken  at  once.  This  year  the  disease 
has  penetrated  to  Saw  Mills  on  the  Gold  Coast,  and  there  is  as 
yet  not  sufficient  protective  measures  enforced  to  prevent  it 
spreading  to  either  the  tin-mining  centres  in  Nigeria,  to  Tarquah 
and  Obuassie,  or  to  the  gold-mining  centres  on  the  Gold  Coast. 

The  interior  of  a  country  offers  no  protection  from  yellow 
fever. 

References 

BERENGER-FERAUD  (L.  J.  B.) — De  la  fievre  bilieuse  comftare'e  avec  la  fievre 

jaune,  Paris,  1874. 
Le  DanteC  (A.) — Precis  de  pathologie  exotique,  Paris,  1905. 
POSKIN     (A.)  —  DAfrique     equatoriale,    climatologie,    nosologie,    hygiene, 

Bruxelles,  1897. 
KERMORGANT   (A.) — "Epidemie    de   fievre  jaune  au  Senegal,  1 900-1901," 

Annates  dhygicne  et  de  me'decine  coloniales ;  "  Maladies  epidemiques 

et  contagieuses  qui  ont  regnees  dans  les  colonies  francaises,  1900, 

1902,  etc.,"  Annates  dhygicne  et  de  medecine  coloniales." 
RlBOT  (A.) — "Rapport  annuel   sur  les   services   d'hygiene   du  Senegal  en 

1905,"  Annates  d'hygiene  et  de  me'decine  coloniales,  1907,  p.  66. 
SCHOTTE  (J.  P.) — Traite  de  la  synoque  atrabilieuse  ou  de  la  fievre  contagieuse 

au  Senegal,  1778,  London,  1785. 
Bouffard  (G.) — "La  defense  de  Bamako  (Haut  Senegal  et  Niger)  contre 

la    fievre    jaune   en    1906,"    Bulletin    de    la    societc    de   pathologie 

exotique,  July  1908. 
LlDIN  (G.) — Coup  doeil  sur  la  climatologie  et  la  pathologie  du   Senegal, 

Paris,  1882. 
BERENGER-FERAUD  (L.  J.  B.)— De  la  fievre  jaime  au  Senegal,  Paris,  1874. 
CARPOT  (Charles) — La  fievre  jaune,  epidemie   de  Pannc'e,  1900,  el  Saint 

Louis  du  Senegal,  Bordeaux,  1901. 


68  YELLOW  FEVER  IN  WEST  AFRICA 

Yellow  Fever  in  Ascension,  Boa  Vista  (Cape 
Verd  Islands  and  Fernando  Po) 

The  interest  attaching  to  yellow  fever  in  these  islands  is 
mainly  from  the  historical  point  of  view.  They  were  ports  of 
call  for  the  West  African  ships  in  the  eighteenth  century,  so 
that  ships  with  yellow  fever  cases  on  board  arrived  regularly 
every  year.  The  medical  authorities  of  the  period  differed  as 
to  whether  the  yellow  fever  which  did  occasionally  break  out 
in  epidemic  form  was  imported  or  of  local  or  endemic  origin. 
Of  course  it  would  be  difficult  to  settle  that  question  now,  as 
both  views  were  readily  possible,  but  at  the  time  they  gave  rise 
to  bitter  controversy. 

On  the  whole,  the  evidence  is  in  favour  of  the  disease  having 
been  endemic  in  the  early  part  of  the  eighteenth  century  or 
even  in  the  seventeenth  century.  Outbreaks  have  also  been 
recorded  in  1863  and  1868. 

Ascension. — According  to  Staff-surgeon  Barry,  yellow  fever 
was  imported  into  Ascension  in  1823  by  the  H.M.S.  Bann,  which 
became  infected  in  Freetown  during  the  yellow  fever  epidemic 
of  1 823- 1 824.  Yellow  fever  broke  out  upon  the  ship  and  32  men 
died.  The  sick  on  arrival  of  the  ship  were  sent  ashore,  and  a 
few  days  afterwards  fever  appeared  amongst  the  garrison,  and 
of  these  17  died.  The  Bann  had  a  crew  of  130,  and  of  these 
38  perished. 

The  same  authority  states  yellow  fever  broke  out  in  1838, 
and  was,  as  before,  attributed  to  a  ship  which  sailed  from  Free- 
town during  an  epidemic. 

According  to  Malcolm,  genuine  yellow  fever  was  present 
in  1818. 

Boa  Vista  {Cape  Verd  Islands). — This  island  is  stated  on  the 
authority  of  Pym  to  have  been  infected  by  the  H.M.S.  Eclair, 
which  arrived  from  Freetown  during  the  epidemic  there  of 
1 844- 1 845. 

On  the  other  hand,  yellow  fever  is  stated  to  have  made  its 


GOLD  COAST  69 

appearance  in  these  islands  in  the  sixteenth  century,  and  that 
they  became  an  endemic  centre  from  which  the  disease  spread 
to  the  African  coast. 

Fernando  Po. — In  1829  yellow  fever  is  said  to  have  been 
introduced  in  its  malignant  form  by  the  H.M.S.  Eden,  but  it 
has  been  also  stated  by  medical  chroniclers  of  the  time  that 
the  disease  might  have  been  endemic  (Pym). 

Outbreaks  are  also  recorded  in  1839  and  1862. 

References 
Fergusson  (Staff-surgeon) — Medical  Reports  of  the  West  African  Station. 
Pym  (Sir  W.) — Observation  upon  Bulam,  Vonale  negroa  or  Yellow  Fever, 

London,  1852;  Second  Report  on  Quarantine,  London,  1852. 
Bryson    (Alec) — Account   of  the  Origin,  Spread,  and  Decline    of  the 

Epidemic  Fevers  of  Sierra  Leone,  1849. 

History  of  Yellow  Fever  in  the  Gold  Coast  Colony 

There  can  be  little  doubt  that  yellow  fever  was  as  prevalent 
on  the  Gold  Coast  in  the  early  part  of  the  nineteenth  century 
as  in  Sierra  Leone. 

From  the  report  of  Staff-surgeon  Tidlie,  quoted  by  Boyle, 
it  appears  that  in  18 19,  out  of  9  new  arrivals,  3  died;  in  1829, 
out  of  4  new  arrivals,  2  died;  and  in  1821,  out  of  7  new 
arrivals,  2  died,  or  two-thirds  of  all  newcomers,  within  twelve 
months  of  arrival.  In  the  same  period  15  of  the  African 
Company  had  died.  It  is  most  probable  that  this  fatal  disease, 
which  attacked  the  newcomers,  was  here,  as  elsewhere  in  the 
tropics — yellow  fever. 

In  a  report  by  Bell,  upon  the  garrison  at  Cape  Coast  Castle 
for  1824,  it  is  stated  that  217  deaths  occurred  in  the  regiments, 
exclusive  of  women  and  children. 

Of  the  first  detachment  of  Europeans,  numbering  128, 
which  arrived  in  April  1823,  only  1  survived;  out  of  109 
women  and  children  who  had  arrived  since  October  1823, 
70  had  died. 

It  is  stated  in  the  report  that  the  cause  of  death  was  bilious 


70  YELLOW  FEVER  IN  WEST  AFRICA 

remittent  fever,  which  usually  terminated  fatally  on  the  third, 
fifth,  or  seventh  day.  Many  of  the  cases  were  as  "  yellow  as  an 
orange."  Boyle  also  mentions  that  an  epidemic  occurred  in 
1824,  similar  to  that  which  took  place  in  Freetown  in  1823. 

In  1824,  out  of  a  third  detachment  of  131  men  disembarked 
in  March  1824,  the  majority  had  died  after  a  few  months  from 
"  remittent  fever  and  dysentery,"  and  the  same  occurred  with 
numerous  subsequent  detachments.  Then  comes  the  usual 
pause,  commencing  from  the  middle  of  the  nineteenth  century, 
probably  due  to  the  withdrawal  of  the  garrison,  and,  therefore, 
of  large  bodies  of  non-immune  new  arrivals. 

At  a  later  date,  following  on  the  commercial  development 
of  the  Colony  and  the  growth  of  the  coast  towns,  yellow  fever 
again  began  to  attract  attention. 

As  had  happened,  however,  in  other  British  West  African 
colonies,  the  disease  was  very  frequently  not  recognised,  and 
was  more  often  wrongly  diagnosed. 

Examination  of  the  case  books  of  the  European  hospitals  in 
the  principal  seaports  are  of  very  great  interest,  for  they  show 
in  the  first  place,  the  difficulties  which  medical  officers 
experienced  in  making  a  diagnosis,  and,  secondly,  the  unwilling- 
ness, as  in  Sierra  Leone,  on  the  part  of  the  medical  authority  of 
the  Colony  to  admit  that  yellow  fever  existed,  in  spite  of  the 
fact,  as  the  careful  records  amply  testify,  of  the  patients  present- 
ing all  the  classical  symptoms  of  fatal  yellow  fever.  The 
stumbling  block  here,  as  in  numerous  other  instances,  being 
occasioned  by  the  confusion  brought  about  by  the  use  of 
the  word  "contagious"  as  applied  to  yellow  fever. 

Examination  of  the  medical  reports  of  the  Colony  show  that 
cases  of  yellow  fever  were  recorded  in  the  following  years : — 
1895  (several  cases)  ;   1897,  4  cases  ;  1902,  2  cases. 

Whilst  on  the  Gold  Coast  I  examined  the  hospital  case 
books  of  Cape  Coast,  Saltpond,  Elmina,  Axim,  and  Accra,  and 
I  find  that  yellow  fever  was  diagnosed  as  such,  and  entered  in 
the  hospital  case  books  at  Cape  Coast  in   1897,  1902,  and   1903  ; 


GOLD  COAST  71 

at  Saltpond  in  1897  and  1902;  at  Elmina  in  1895;  and  at 
Accra  in  1899. 

In  1899  Dr  Elliott,  who  had  had  four  years'  experience  in 
the  Gold  Coast,  published  in  detail  three  cases  of  yellow  fever 
which  he  attended  at  Saltpond. 

He  alludes  to  the  reluctance  prevalent  against  the  diagnosis 
of  yellow  fever  and  the  tendency  to  regard  all  fevers  as 
malarial. 

In  1901  Dr  S.  O.  Browne  published  a  case  of  yellow  fever 
which  he  attended  at  Saltpond. 

In  addition  to  these  well-marked  cases  which  were  diagnosed 
at  the  time  by  the  physicians  in  charge  as  genuine  yellow  fever, 
the  histories  of  the  cases,  in  my  opinion,  also  furnish  unmistak- 
able proof  of  the  almost  continuous  occurrence  of  yellow  fever 
for  the  past  fifteen  years. 

The  evidence  is  all  the  more  trustworthy,  for  the  medical 
officers,  who  recorded  the  symptoms,  were  not  looking  out  for 
yellow  fever. 

The  histories  also  show  the  difficulty  which  a  medical 
officer  experienced  in  interpreting  the  symptoms  on  the 
supposition  that  the  disease  might  be  malarial  fever. 

From  my  analyses  of  the  case  books,  I  conclude  that  yellow 
fever  existed  in  addition  to  the  above  dates  in  the  following 
places  on  the  coast : — 

(1)  Elmina.     History  of  Cases  examined  since  1895  up  to  date 

In  March  1895,  a  case  was  diagnosed  as  "hepatic  fever," 
and  ended  fatally. 

The  symptoms  were  :  great  prostration,  black  vomit  (coffee- 
like grounds),  eyes  and  skin  yellow,  suppression  of  urine. 

In  April  1895,  a  case  diagnosed  as  "malarial  fever":  it 
terminated  fatally ;  the  symptoms  were :  intense  head  and 
back  ache,  nausea  and  epigastric  pain,  black  vomit;  temperature 
103-4°,  pulse  92.  A  post-mortem  examination  showed  skin 
yellow,  stomach  containing  black  vomit,  congestion  of  the  skin. 


72  YELLOW  FEVER  IN  WEST  AFRICA 

The  doctor  in  charge  of  the  case  strongly  suspected  yellow 
fever,  as  also  in  the  preceding  case. 

In  January  1902,  a  case  was  diagnosed  as  "  resembling 
yellow  fever."  The  symptoms  were :  intense  headache, 
albuminuria,  intense  vomiting,  black  vomit,  black  motions, 
death. 

The  case-book  shows  in  addition  numerous  histories  of  cases 
which  might  well  have  been  both  mild  and  severe  cases  of 
yellow  fever. 

(2)  Quitta 

I  examined  the  cases  in  the  case-book  from  1888- 1900. 

In  1894  a  new  arrival  was  taken  ill,  and  a  diagnosis  of 
"malignant  remittent  fever"  was  made;  temperature  104; 
conjunctivae  yellow ;  vomiting,  urine  black  and  bloody ; 
delirium ;  albuminuria,  followed  by  suppression  of  urine ; 
convulsions ;  and  death. 

The  medical  officer  states  : — 

"  I  cannot  help  being  struck  by  the  severe  and  persistent 
symptoms  of  this  case,  particularly  the  vomiting,  which  nothing 
seemed  to  affect.  In  fact,  I  can  scarcely  see  the  difference 
between  such  a  case  as  the  above  and  yellow  fever." 

In  1900  a  suspicious  case  also  occurred,  the  diagnosis  being 
"  remittent  fever." 

The  medical  officer  stated  the  probability  that  the  patient 
might  be  suffering  from  yellow  fever  suggested  itself;  but  as 
the  temperature  showed  no  signs  of  subsiding,  and  there  was 
no  congestion  of  the  face,  it  was  decided  that  it  would  be  better 
to  wait  and  see,  than  to  suggest  the  possibility  to  headquarters. 

(3)  Saltpond.     Examination  of  Cases  from  1889  to  1903 

In  1895  a  case  occurred — diagnosed  as  "remittent  fever" — 
terminating  fatally.  It  was  characterised  by  jaundice  ;  tempera- 
ture 105-8;  pulse  60;  black  vomit;  suppression  of  urine; 
hiccough  ;  intense  headache. 


GOLD  COAST  73 

There  were  also  about  this  time  numerous  other  cases  with 
a  similar  diagnosis  presenting  very  suspicious  symptoms. 

In  1897  yellow  fever  is  diagnosed. 

In  July  1897,  a  case  was  diagnosed  as  hemoglobinuria  and 
acute  nephritis. 

It  was  not  diagnosed  as  yellow  fever  because  of  the  absence 
of  black  vomit.  Faget's  sign,  jaundice  and  hiccough,  were, 
however,  present,  and  haemorrhage  from  gums  as  well  as 
vomiting  of  dark  bilious  fluid  is  mentioned. 

So,  considering  there  were  other  cases  in  that  year,  it  is  not 
improbable  that  this  was  also  a  case  of  yellow  fever. 

In  June  1898  a  case  occurred,  ending  fatally,  diagnosed  as 
" '  acute '  delirious  malignant  malarial  fever." 

The  patient  was  so  maniacal  that  he  had  to  be  handcuffed  ; 
temperature  105-4  and  rose  to  107-2  ;  skin  jaundiced,  head  and 
shoulders  intensely  congested,  nausea,  vomiting,  coma,  and 
death.  Post-mortem :  Cutaneous  haemorrhages,  mucous 
membrane  of  stomach  intensely  congested,  stomach  contained 
dark  green  treacly  mass,  liver  saffron  yellow,  with  patches  of 
congestion.  This  might  well  have  been  a  case  of  yellow  fever, 
in  spite  of  the  fact  that  it  is  stated  "  pigmented  corpuscles  were 
found  in  the  blood." 

In  1 90 1  two  cases  were  diagnosed  as  yellow  fever;  but  in 
addition,  in  each  year  there  occurred  cases  which,  when  we 
know  that  there  were  genuine  cases  of  yellow  fever,  might 
equally  well  have  been  cases  of  yellow  fever.  The  diagnoses 
made  were  usually  "  bilious  remittent  fever." 

(4)  Axim.     Examination  of  Case-Books  from  1906-1910 

In  1905  the  medical  officer  in  charge  of  a  case  which 
occurred  in  that  year  at  Axim,  and  which  terminated  fatally, 
is  now  of  the  opinion  that  the  case  was  one  of  yellow  fever. 

In  this  year,  19 10,  a  death  occurred  from  yellow  fever  and 
was  reported.     The  symptoms  were,  however,  not  well  marked. 

Later   on  in  1910  another   fatal   case  occurred,  which  was 


74  YELLOW  FEVER  IN  WEST  AFRICA 

diagnosed  as  "  remittent  fever."  The  chief  symptoms  were : 
temperature  104-9;  pulse  rate  from  1 10-120.  Temperature  did 
not  yield  to  large  doses  of  quinine. 

Another  case  was  diagnosed  as  "  pernicious  remittent  fever," 
and  proved  fatal. 

The  symptoms  were :  intense  headache ;  temperature  102-8  ; 
pulse  88  ;  delirium,  and  finally  coma. 

The  doctor  in  charge  suspected  yellow  fever. 

(5)  Cape  Coast 

In  1903  Dr  G.  L.  Barker  wrote  to  the  acting  principal 
medical  officer  at  Accra  reporting  a  case  of  yellow  fever,  and 
he  states  that  "  this  makes  the  fifth  case  this  year." 

The  medical  officer  who  diagnosed  the  case  was  Dr  Rome 
Hall,  and  the  principal  medical  officer,  in  writing  a  memor- 
andum to  the  colonial  secretary,  states  : — 

"  I  regret  to  say  that  I  am  obliged  to  take  the  alarmist 
statement,  made  by  Dr  Rome  Hall,  with  a  large  amount  of 
doubt." 

In  1895  a  case  of  remittent  fever  is  diagnosed,  in  which  the 
characteristics  are  :  congestion,  intense  headache,  temperature 
108-8,  and  pulse  52.  The  doctor  in  charge  mentions  that  the 
curious  point  about  the  case  was  that  "  the  pulse  continued  to 
get  slower  as  the  temperature  got  higher."  The  case,  however, 
recovered. 

Another  case  of  remittent  fever  was  diagnosed,  which  ended 
fatally;  temperature  105;  jaundice;  great  weakness,  black 
motion,  anorexia;  delirium;  patient  then  slowly  rallied;  this 
was  followed  by  a  relapse,  coma,  and  death. 

In  this  year  there  were  several  other  very  suspicious  cases. 

In  1901  a  series  of  fatal  cases,  diagnosed  as  "remittent 
fever,"  occurred  one  after  the  other,  in  which  there  were 
characteristic  symptoms :  jaundice,  delirium,  great  weakness, 
and  coma ;  in  one  case  the  vomit  contained  bloody  matter.  In 
1902  a  case,  diagnosed  as  "pernicious  malaria,"  occurred,  and 


GOLD  COAST  75 

ended  fatally;  temperature  103;  pulse  80;  intense  gastric 
symptoms  ;  black  vomit,  delirium,  haemorrhage  from  the  mouth, 
skin  and  conjunctivae  yellow ;  the  physician  notes  that  there 
was  no  black  water,  and  that  the  pulse  rate  was  not  in  propor- 
tion to  the  temperature. 

Several  other  fatal  cases  also  occurred  in  March  and  June 
1902  ;  in  one,  the  diagnosis  of  "continued  fever"  was  made.  In 
this  case  there  was  black  vomit  and  black  motions. 

In  another  case  a  diagnosis  of  "  hyperpyrexia!  fever  "  was 
made.  The  skin  and  conjunctivae  were  yellow,  and  the  post- 
mortem showed  the  liver  yellow,  the  mucous  membrane  of 
stomach  and  intestines  dotted  over  with  fine  sub-mucous 
haemorrhages. 

Another  case  was  diagnosed  as  "remittent  fever."  No 
parasites  were,  however,  found  in  the  blood.  Vomiting  was 
persistent ;  delirium,  skin  yellow,  melena ;  post-mortem  showed 
stomach  and  intestines  intensely  congested. 

In  another  case  a  diagnosis  of  "malarial  fever"  was  made; 
temperature  108-2  ;  and  it  was  noted  that  the  pulse  was  very 
slow  in  comparison  with  the  temperature.  There  was  persistent 
black  vomiting,  melena,  albuminous  urine,  conjunctivae  and 
skin  yellow ;  post-mortem  examination  showed  intense  conges- 
tion of  the  stomach  and  kidneys.  Then  in  July  of  the  same 
year  the  doctor's  suspicions  were  aroused,  and  he  had  no  longer 
any  hesitation  in  diagnosing  "  yellow  fever,"  and  two  fatal  cases 
are  recorded. 

It  is  therefore  exceedingly  probable  that  the  other  cases 
also  were  yellow  fever. 

In  the  commencement  of  1903,  Dr  Rome  Hall  diagnosed  a 
case  of  yellow  fever,  and  he  records  minutely  the  symptoms. 
He  states  that  he  first  considered  the  case  to  be  one  of  black 
water,  but  the  presence  of  albumin  in  the  urine  cast  doubt  upon 
the  diagnosis.  He  states  "that  the  post-mortem  record 
appeared  to  be  universally  in  favour  of  yellow  fever.  The 
writer  then  states  that  yellow  fever  has  several  times  appeared 


76  YELLOW  FEVER  IN  WEST  AFRICA 

on  the  French  Ivory  Coast  and  in  Senegambia.  The  Ivory 
Coast  is  only  150  miles,  or  forty-eight  hours  away  from  Cape 
Coast,  and  that  at  the  present  time  quarantine  is  declared 
against  the  Ivory  Coast."  He  then  states  that  "  the  Stegomyia 
are  swarming  in  the  merchants'  tanks,  and  in  the  tanks  of  the 
natives." 

Dr  Savage,  of  Cape  Coast,  who  saw  the  fatal  cases  of  1902- 
1903,  informs  me  that  there  was  no  question  about  the  diagnosis 
of  yellow  fever. 

(6)  Extracts  from  Case-books,  Accra 

CASE  A.  J.  S.,  a  new  arrival,  history  of  being  bitten  at 
Winnebah,  arrived  in  Accra,  April  1904. 

igt/i  April. — Patient  felt  unwell. 

2 1  st  April. — Temperature  1040,  pains  over  body. 

22nd  April. — Temperature  104- 1050,  urine  scanty,  albumin 
present. 

2^rd  April. — Vomiting  black  coffee-ground  material,  stools, 
tarry. 

2^th  April. — Vomiting  persistent  and  violent,  hiccough,  tarry, 
stools,  mind  wandering,  pulse  120,  temperature  1050,  coma 
followed  by  death.  The  medical  officer  regarded  the  disease 
as  malarial. 

Case  R.}  April  1899. — Notes  very  meagre,  but  the  diagnosis 
of  yellow  fever  was  made.  The  symptoms  of  black  vomit, 
yellow  blotchy  skin,  and  intense  headache  were  present, 
temperature  1050.  On  the  other  hand,  there  was  no  albu- 
minuria. 

Case  A.  W.,  patient  died. — Diagnosis,  "subacute  rheuma- 
tism," June  1905.  The  symptoms  were  pains  in  joints ; 
temperature  102-4° ;  scanty  urine  with  trace  of  albumin ;  later 
on  vomiting  became  a  prominent  symptom,  accompanied  by 
hiccough,  mind  wandering,  pulse  weakened,  coma,  and  death. 

Post-mortem  examination  showed  deeply  congested  kidneys, 
and  the  note  is  made  that  immediately  after  death,  the  body 
assumed  an  intensely  yellow  colour ;  this  is  a  sign  which,  in  my 
opinion,  is  extremely  characteristic  of  yellow  fever. 


GOLD  COAST  77 

Case ,     merchant,    July     1905. — Diagnosis,     "bilious 

remittent  fever."  The  symptoms  on  19th  July  were  intense 
headache,  temperature  ioi-8°,  later  in  day  1040.  Albuminuria, 
quinine  little  effect  upon  the  temperature,  vomiting  became 
persistent,  and  patient  became  drowsy,  urine  much  diminished, 
death  on  the  24th. 

Post-mortem  examination  showed  enlarged  liver  (colour  not 
stated),  and  deeply  congested  kidneys. 

CASE  Rev. ,   February   1906. — Diagnosis,   "remittent 

fever."  Symptoms,  1st  February:  intense  headache,  temper- 
ature 103- 1040.  Gastric  irritability,  urine  scanty  with  albumin. 
On  4th  February  commenced  to  have  black  vomit  (coffee- 
ground  material),  collapse,  death. 

(7)   Tarquah  District.     Mantrain  (1902)  and  Saw  Mills  (19 10) 

In  1902,  8  men  out  of  a  staff  of  14  died  within  about  three 
weeks  of  one  another.  The  doctor  in  charge  also  died ;  the 
others  stampeded. 

In  a  report  which  was  sent  from  Tarquah  on  14th  June, 
1903,  to  the  principal  medical  officer  at  Accra,  the  following 
statement  is  made : — "  I  am  informed  that  death  in  several 
cases  occurred  from  hyperpyrexia,  and  that  the  administration 
of  quinine,  even  in  hypodermic  injections  in  large  doses,  failed 
to  reduce  the  temperature.  In  four  of  the  cases  death  took 
place  four  days  after  the  onset  of  the  illness.  Dr  Macdonald 
examined  his  own  blood  during  his  illness,  and,  it  is  stated 
found  the  malarial  parasites. 

The  writer  formed  the  opinion  that  the  disease  was  "  pernici- 
ous malaria  with  hyperpyrexia,"  and  he  notes  that  no  mosquito 
nets  were  used  with  two  exceptions. 

In  this  year  (1910)  a  case  of  genuine  yellow  fever  has 
occurred  at  Saw  Mills,  a  small  camp  close  to  Tarquah,  and  I 
am,  therefore,  of  opinion  that  it  is  not  unreasonable  to  suppose 
that  the  fatal  epidemic  of  Mantrain  was  genuine  yellow  fever, 
especially  in  view  of  the  fact  of  the  enormous  numbers  of 
Stegomyia. 


78  YELLOW  FEVER  IN  WEST  AFRICA 

Conclusions. —  I  am  convinced  from  the  preceding  examina- 
tion of  the  case-books  that  there  were  many  more  cases  of  mild 
yellow  fever  which  were  diagnosed  as  "  remittent  fever " ;  it 
was  only  when  a  case  died,  and  when  black  vomit,  slow  pulse, 
and  albuminuria  became  marked  features,  that  the  suspicions  of 
the  doctors  in  charge  were  aroused. 

The  mild  cases  passed  unrecognised. 

If  additional  proof  were  wanted  to  demonstrate  the  essenti- 
ally endemic  character  of  yellow  fever  in  West  Africa,  it  is 
furnished  by  the  history  and  progress  of  the  outbreak  of  yellow 
fever  in  the  year  1910  on  the  Gold  Coast. 

In  the  first  place,  yellow  fever  broke  out  at  three  distinct 
points :  Secondee,  Saw  Mills,  and  Axim.  In  the  second  place, 
it  shows  the  difficulty  which  the  medical  officer  had  at  first  in 
deciding  whether  he  was  face  to  face  with  yellow  fever  or  not. 

Little  time  was,  however,  lost  in  arriving  at  a  final  diagnosis. 
I  am  convinced  from  analysis  of  many  hospital  case-books  that 
in  every  probability  a  similar  difficulty  has  presented  itself  to 
medical  officers  in  the  past  upon  many  occasions,  and  that 
medical  officers  have  refrained  from  giving  the  more  serious,  or, 
as  it  has  been  termed,  "  alarmist,"  diagnosis  of  yellow  fever.  In 
support  of  this  contention  the  following  memorandum  is  of  the 
greatest  interest : — 

Outbreak  of  Yellow  Fever,  Secondee,  1910 

The  Colonial  Hospital,  Secondee, 
qth  May  19 10, 

"  SiRj I  have  the  honour  to  report  that  recently  there  have 

been  three  cases  of  fever  here,  two  of  which  came  from  the  same 
bungalow,  namely,  Mr  and  Mrs  C,  and  more  recently  Mr  W., 
Supervisor  of  Customs,  that  present  unusual  symptoms. 

"  Mrs  C.  was  removed  into  hospital  with  a  temperature  of 
i05°j  persistent  vomiting,  and  severe  headache.  She  later 
became  intensely  jaundiced,  but  eventually  made  a  good 
recovery,  and  has  proceeded  to  England. 

"  Fifteen  days  later  Mr  C.  was  removed  to  hospital  with  a 


1910  OUTBREAK  79 

temperature  of  1030,  intense  headache,  diarrhoea,  injected  eyes. 
He  suddenly  collapsed,  and  died  three  days  later. 

"  Mr  W.  got  a  sudden  attack  of  vomiting  with  a  temperature 
I03"6°  at  night.  He  now  has  some  diarrhoea,  and  his  eyes  are 
injected  ;  jaundice  seems  coming  on.  I  have  treated  each  case 
with  intramuscular  injection  of  quinine  until  chinchonised.  The 
first  case  had  no  albuminuria ;  in  the  second  I  was  unable  to 
procure  a  specimen,  as  he  could  only  micturate  when  defalcating. 
Up  to  the  present  I  have  only  been  able  to  procure  about  two 
drams  of  Mr  W.'s  urine,  which  shows  marked  albumin  with 
nitric  acid  (in  the  cold). 

"  These  cases  show  a  remarkable  likeness  to  a  series  of  cases 
in  Accra,  when  I  was  there  in  1905,  all  of  which  were  fatal. 
I  mentioned  two  cases  to  Dr  Tweedy  when  he  was  here  on  his 
way  to  Tamele,  who  told  me  that  he  had  met  with  similar  in 
Cape  Coast ;  also  I  had  discussed  them  with  Dr  Slack.  Without 
wishing  to  cause  unnecessary  alarm,  I  much  fear  yellow  fever 
may  be  present  here,  and  beyond  Drs  Slack  and  Tweedy,  the 
only  other  person  I  have  mentioned  the  matter  to  is  the  Acting 
Provincial  Commissioner,  Mr  Furley. 

"  Will  you  inform  me  by  telegram  what  steps,  if  any,  I  can 
take  to  prevent  an  epidemic,  as  Stegomyia  are  very  prevalent 
here. 

"C.  H.  D.  Ralph." 

The  outbreak  of  yellow  fever  which  took  place  in  Secondee 
this  year,  19 10,  differs  in  no  essential  respect  from  all  previous 
ones  in  West  Africa,  or  in  the  other  parts  of  the  tropical  world. 
It  is  a  matter  for  congratulation,  however,  that  this  disease  was 
early  recognised,  and  that  the  medical  authority  of  the  colony 
did  not  lose  a  day  in  taking  preventive  measures. 

The  outbreak,  which  started  in  March  and  ended  in  June, 
was  a  comparatively  small  one — about  1 3  cases — but  as  in  all 
these  outbreaks,  so  here  it  is  more  than  probable  that  there 
were  other  mild  cases  which  were  not  diagnosed  until  the  severe 
cases  drew  attention  to  the  nature  of  the  disease ;  there  were 
10  cases  amongst  the  white  population  and  3  amongst  the 
native.     The   native  population   is   large,  and  the  white  com- 


80  YELLOW  FEVER  IN  WEST  AFRICA 

paratively  very  small  (about  120).  Therefore,  as  in  all  previous 
epidemics,  the  comparative  percentage  mortality  amongst  the 
whites  was  very  much  greater  than  amongst  the  natives ;  in 
fact,  there  is  no  comparison.  Of  the  whites  who  were  attacked, 
it  is  significant  that  they  had  been  in  Secondeefor  periods  vary- 
ing from  a  few  days  to  a  few  months  immediately  prior  to  the 
outbreak. 

The  mortality  in  proportion  to  the  number  of  cases  notified 
was  very  high.  All  the  cases  proved  fatal  with  one  exception. 
The  high  mortality  rate  is  of  common  occurrence  in  countries 
where  the  medical  authorities  are  not  suspecting  yellow 
fever. 

The  chief  symptoms  recorded  are  typical  of  yellow  fever, 
viz.,  violent  headache,  yellow  sclerae,  jaundice,  or  sudden  turning 
yellow  immediately  after  death,  albuminuria,  suppression  of 
urine,  delirium,  Faget's  sign,  black  or  black-speckled  vomit, 
coma.  Where  quinine  was  administered  it  did  not  appear  to 
have  any  effect. 

Post-mortems  showed  : — 

Boxwood  liver,  congested  kidneys,  stomach  and  intestines, 
otherwise  organs  normal. 

In  the  opinion  of  the  senior  sanitary  officer,  Dr  Rice,  and 
of  the  acting  principal  medical  officer,  and  also  of  the  other 
medical  officers  who  were  associated  with  them  in  the  investiga- 
tion of  the  1910  outbreak  of  yellow  fever  in  Secondee,  the  disease 
was  of  endemic  origin.  The  following  are  Dr  Rice's  conclusions, 
and  with  them  I  agree,  after  examination  of  all  the  circumstances 
on  the  spot : — 

"  That  yellow  fever  had  previously  broken  out  in  the  Gold 
Coast  is  well  shown  in  the  extract  which  the  acting  principal 
medical  officer  has  furnished  from  the  annual  reports. 

"  I  am  a  comparatively  recent  importation  to  the  Gold  Coast, 
and  hence  am  not  in  a  position  to  state  what  were  the  reasons 
which  led  the  authorities  to  call  this  disease,  for  so  many  years, 
by  another  name.     A  study  of  the  case-books  from  the  various 


1910  OUTBREAK  81 

parts  of  the  Gold  Coast  leave  upon  one's  mind  the  impression 
that  in  many  instances  Europeans  who  have  been  returned 
as  having  died  of  malignant  malaria,  have  really  died  of  yellow 
fever.  Sometimes  the  medical  officers  have  discussed  the 
possibility  of  certain  cases  being  yellow  fever,  and  in  other 
instances  they  have  called  it  so,  but  in  the  annual  returns  this 
disease  has  usually  been  conspicuous  by  its  absence,  and, 
apparently,  whether  by  accident  or  design,  it  had  never  been 
given  official  recognition. 

"  In  reply  to  telegrams  from  headquarters  as  to  the  source 
of  infection,  I  replied  that  I  considered  yellow  fever  to  be  endemic 
among  the  native  population  of  West  Africa,  and  I  am  still  of 
that  opinion.  There  is  no  other  hypothesis  that  to  my  mind 
can  explain  this  and  previous  outbreaks.  The  precise  conditions 
that  are  necessary  for  the  disease  to  be  communicated  to  the 
non-immune  white  population  are  as  yet  unknown,  but  two 
conditions  are  always  present  when  non-immunes  are  attacked, 
viz. : — 

"  i.  They  live  in  native  towns  unsegregated  from  natives. 

"  2.  Under  conditions  which  favour  the  breeding  of  the 
enormous  numbers  of  Stegomyia. 

"  Dr  W.  C.  Gorgas  makes  an  interesting  statement  on  this 
subject  in  the  Proceedings  of  the  Canal  Zone  Medical  Associa- 
tion, 1908,  viz. : — '  That  a  certain  proportion  of  Stegomyia  must 
be  present  in  a  locality  for  the  spread  of  yellow  fever.' 

"  It  is  customary  when  an  outbreak  of  yellow  fever  occurs 
to  look  for  the  ship  that  is  always  supposed  to  have  brought 
the  infection,  in  spite  of  the  fact  that  to  bring  yellow  fever  to 
West  Africa  is  equivalent  to  carrying  coals  to  Newcastle. 

"  Two  ships,  the  barques  Montgomery  and  Cosmos,  had 
brought  cargoes  to  the  port  from  America.  The  Montgomery 
from  Gulf  Port,  Mississippi,  arrived  in  Sekondi  on  the  17th  of 
January,  and  left  on  the  7th  of  March.  The  voyage  lasted 
seventy-five  days,  and  the  ship  had  a  clean  bill  of  health. 

"  The  Cosmos,  from  Mobile,  United  States  of  America, 
arrived  at  Sekondi  on  the  5th  of  March,  and  left  on  the  10th 
of  April,  having  been  forty-five  days  on  the  voyage,  with  a 
clean  bill  of  health,  so  these  ships  may  be  regarded  without 
suspicion." 


82  YELLOW  FEVER  IN  WEST  AFRICA 

Extracts  from  the  A  nnual  Medical  and  Sanitary  Report \ 
1895,  Gold  Coast  Colony 

"  General  Health  of  the  Colony. — The  general  health  of  the 
colony  was  extremely  bad  during  the  period,  the  endemic 
fever  assuming  a  pseudo-epidemic  form  of  a  malignant  type 
closely  approaching  in  its  clinical  manifestations  the  vomito 
negro  or  yellow  fever  of  the  West  Indies.  The  death-rate  was 
enormous  among  Europeans,  and  the  excitement  induced 
thereby  amounted  almost  to  a  panic  and  served  to  intensify 
the  fatal  tendencies  of  the  prevailing  fever  in  the  latter  part  of 
the  year. 

"  At  the  beginning  of  the  month  the  general  health  of  the 
town  of  Accra  was  bad,  and  some  cases  of  the  malignant  type  of 
fever  which  during  the  first  six  months  of  the  year  prevailed 
on  other  parts  of  the  coast  appeared.  Three  deaths  occurred 
from  it  amongst  the  officials  of  the  African  Direct  Telegraph 
Company  in  connection  with  this  disease  (which,  in  my 
opinion,  is  of  the  same  type  as  has  during  the  last  few  years 
appeared  occasionally  at  Sierra  Leone,  Bonny,  Lagos,  and  other 
places  on  the  west  coast  of  Africa)." 

Cape  Coast. — During  the  first  quarter  the  health  of  the 
European  residents  was  extremely  bad,  and  judging  from  the 
death-rate,  worse  than  it  has  been  for  some  years.  "  The  pre- 
valent diseases  were  remittent  fever  and  diarrhoea.  The  former 
seems  to  have  been  of  a  very  pernicious  nature,  with  a  tendency 
to  hyperpyrexia,  suppression  of  urine,  and  amaurosis "  (Dr 
Lyons).  Four  deaths  occurred  among  the  non-official 
Europeans. 

During  the  second  period  the  same  condition  of  things 
persisted,  and  the  mortality  was  great ;  among  officials  2 
died,  and  among  non-officials  6. 

Elmina. — The  first  quarter  was  marked  by  an  unusual  pre- 
valence of  malarial  fever.  Out  of  a  grand  total  of  10  officials,  8 
suffered  from  attacks  of  fever  more  or  less  violent,  and  of  these 


GOLD  COAST  83 

3  died  and  2  were  invalided.  "  The  non-official  Europeans  did 
not  suffer  so  severely  :  out  of  a  grand  total  of  14,  i  was  invalided 
and  died  three  days  later  at  sea.  The  prominent  features  of 
the  various  fatal  cases  were  blood  destruction,  suppression  of 
urine,  hyperpyrexia,  and  heart  failure"  (Dr  Elliott).  During 
the  second  quarter  "  the  unhealthiness  which  characterised  the 
previous  quarter  was  continued  into  the  early  part  of  May, 
when  the  onset  of  the  wet  and  cold  season  inaugurated  a  general 
change  for  the  better." 

"  Saltpond  (first  quarter). — The  general  health  of  the  Euro- 
peans was  most  unsatisfactory,  the  prevalent  diseases  being 
remittent  and  intermittent  fevers  and  dysentery.  One  official 
died  from  remittent  fever,  complicated  with  suppression  of  urine 
(Mr  Trigg). 

"Saltpond. — In  1895  I  was  stationed  for  some  time  in  Salt- 
pond,  during  which  period  an  outbreak  of  a  very  malignant 
type  occurred  amongst  the  limited  European  community. 
Amongst  the  cases  were  Father  Riche,  of  the  Catholic  Mission ; 
Mr  Trigg,  of  the  Public  Works  Department ;  Mr  Moran,  a  trader ; 
and  another  merchant.  One  of  these  cases,  Mr  Moran, 
recovered.  The  cases  presented  the  features  of  rapid  onset, 
high  fever,  which  gradually  subsided,  jaundice,  and  albuminuria 
in  the  3  fatal  cases,  black  vomit,  suppression  of  urine,  coma 
with  convulsions  and  death,  and  at  no  time  was  haemoglobinuric 
urine  passed  in  any  case.  A  prominent  fact  which  lasted  for 
ever  in  my  memory  was  the  existence  of  a  peculiarly  offensive 
odour  and  the  passage  of  peculiar  tarry  motions,  the  immediate 
circumference  of  which  in  a  bed-pan  or  chamber  pot  presented 
a  look  of  altered  blood.  All  these  fatal  cases  presented  a 
peculiar  delirious  restlessness  before  absolute  coma  set  in. 
Although  I  was  inclined  to  regard  these  as  cases  of  yellow  fever, 
I  was  in  possession  of  such  information  that  I  knew  such  a 
declaration  would  be  useless  on  my  part,  and  in  this  connection 
I  invite  attention  to  paragraphs  12,  14,  and  31  of  the  Annual 
Medical  Report  for  the  year  1895.     Mr   Trigg  lived   in  hired 


84  YELLOW  FEVER  IN  WEST  AFRICA 

quarters  in  a  native  house,  and  the  other  Europeans  lived  in 
the  town.  The  second  Catholic  Father  was  invalided  very  soon 
after  the  death  of  Father  Riche.  I  closed  their  house,  and 
condemned  it.  Some  time  after,  when  Bishop  Albert  and 
Father  Wade  arrived  in  Saltpond,  I  did  not  allow  them  to 
occupy  the  quarters,  and  told  them  what  I  thought  the  cause  of 
the  sickness  was.  At  this  time  the  mosquitos  were  plentiful 
at  Saltpond  in  the  native  quarters,  but  I  was  not  able  to  identify 
species. 

"  In  the  case  of  Mr  Trigg  I  recollect  wishing  to  try  pilocarpine, 
owing  to  the  suppression  and  to  the  fact  that  the  skin  remained 
dry.  I  also  recollect  improvising  a  vapour  bath  in  the  hope  of 
starting  diaphoresis. 

"  There  had  been  much  sickness  and  mortality  prior  to  this  at 
Elmina  and  Cape  Coast,  and  my  leave  was  twice  put  off,  owing 
to  the  death  of  the  medical  officer  deputed  to  relieve  me,  one, 
Dr  Lyons,  being  invalided  and  dying.  Soon  after,  the  other, 
Dr  Conran,  died  at  Cape  Coast.  At  this  time  much  difference 
of  opinion  existed  as  regards  the  sickness,  but  as  far  as  my 
recollection  goes  the  majority  of  the  medical  officers  who  saw 
cases  believed  they  were  dealing  with  yellow  fever,  and  I 
heard  that  Drs  Lyons  and  Conran  had  succumbed  to  this 
disease."     (From  report  furnished  by  Dr  Garland.) 

Extract  from  Report  for  1896 

The  general  health  of  the  colony  during  the  year  under 
review  shows  little  or  no  improvement  on  that  of  the  previous 
year.  This  year  there  were  amongst  the  European  population 
11  deaths  of  officials  and  30  non-officials,  as  against  15  and  23 
respectively  during  1895,  the  number  invalided  being  23  officials 
and  35  non-officials,  against  26  and  32  in  1895. 

This  high  rate  is  to  be  attributed  to  the  fact  that  the  epidemic 
of  the  malignant  type  of  fever  which  prevailed  during  the  last 
half  of  1895  continued  during  the  first  four  months  of  this  year, 
the  period  during  which  the  greater  number  of  deaths  occurred. 


GOLD  COAST  85 

In  Accra  there  was  a  good  deal  of  sickness  during  the  first 
half  of  the  year,  but  the  last  half  was  exceptionally  healthy, 
more  especially  amongst  the  European  officials ;  this,  no  doubt, 
being  due  to  the  fact  that  the  majority  now  live  outside  and  at 
a  considerable  distance  from  the  native  town. 

Extract  from  Report,  1897 

During  the  second  quarter  of  the  year  Cape  Coast  and 
Saltpond  suffered  from  an  outbreak  of  fever,  affecting,  so  far  as 
I  am  aware,  Europeans  only,  of  the  same  nature  as  that  which 
scourged  Elmina  and  Cape  Coast  early  in  the  year  1S95,  and 
which  later  in  the  year  appeared  in  Accra,  to  which  the  chief 
medical  officer  alluded  in  paragraph  1,  Report  for  1895. 

Health  of  Europeans  at  the  Various  Stations 
Saltpond. — No  deaths  among  officials.  There  were  6 
deaths  among  non-officials,  equal  to  a  ratio  of  67-4  of  the  total 
strength  of  Europeans  in  the  station  for  the  year.  No  officials 
were  invalided,  but  3  non-officials  were.  As  regards  the 
causes  of  death,  1  was  a  case  of  cerebral  haemorrhage  in  an 
elderly  man ;  2  were  acute  nephritis  complicating  malarial 
fever,  and  3  were  cases  presenting  the  classical  symptoms 
of  yellow  fever.  The  health  of  the  officials  was  good,  that  of 
the  non-officials  exceedingly  bad.  The  non-official  Europeans, 
that  is,  the  agents  of  the  European  mercantile  firms,  live  in 
houses  which  are  grouped  round  the  lagoon,  whereas  the 
officials'  quarters  are  situated  at  some  distance  from  the  lagoon 
and  close  to  the  beach.  This  is  sufficient  to  account  for  the 
immunity  enjoyed  by  the  officials,  while  the  European  employees 
of  the  mercantile  firms  were  suffering  from  all  the  varieties  of 
fever  that  are  met  with  on  the  coast. 

Cape  Coast. — There  were  12  deaths  among  non-officials, 
equal  to  a  rate  of  50  per  1000 ;  there  were  no  deaths  among  the 
officials.  Causes  of  death  were  chiefly  bilious  remittent  fever. 
There  was  1  from  yellow  fever. 


86  YELLOW  FEVER  IN  WEST  AFRICA 

A.  Swanzy  died  at  Accra,  25th  April  1904,  case  being 
clinically  similar  to  yellow  fever.  He  was  nursed  by  Miss 
Fraser,  who  went  on  leave  27th  June,  died  on  3rd  July  at  sea ; 
symptoms  alleged  to  be  like  yellow  fever. 

Note  furnished  by  Dr  Garland,  Acting  Principal  Medical  Officer 

"  I  concur  with  the  opinion  of  Sir  Rubert  Boyce  that  yellow 
fever  existed  for  a  considerable  time  and  was  not  officially 
recognised.  However,  there  were  occasions  in  1894  and  1895, 
and  subsequently,  when  many  of  the  medical  officers  of  this 
colony  openly  stated  they  v/ere  convinced  that  they  were 
dealing  with  this  disease  ;  and  that  the  matter  was  one  actually 
under  controversy,  is  proved  by  the  following  extracts  by  the 
chief  medical  officer  from  the  Medical  Report  for  1895  : — 

"  Three  cases  in  Accra  occurred  in  one  house.  During  this 
year,  1895,  I  had  4  cases  of  yellow  fever  at  Saltpond,  3  of  whom 
died.  I  wrote  to  some  of  my  colleagues  at  Cape  Coast,  as 
I  know  that  determination  had  been  shown  in  favour  of  the 
disease  being  declared  a  non-infectious  bilious  remittent  fever. 
I  only  learned  that  more  than  one  of  the  members  of  our  staff 
considered  they  were  dealing  with  yellow  fever,  but  that  the 
diagnosis  would  not  be  accepted. 

"  I  am  inclined  to  believe  that  this  outbreak  originated  at 
Elmina  in  1894,  where  several  Europeans  died  and  which  had 
previously  borne  the  reputation  of  being  a  most  healthy  station. 
After  a  considerable  lapse  of  time  an  outbreak  of  a  fatal  type  of 
fever  occurred  at  Accra  in  1896,  and  I  understand  that  there 
was  a  severe  outbreak  at  Little  Popo  some  time  after  this  ;  but 
there  is  no  opportunity  of  arriving  at  the  facts  with  regard  to  the 
latter. 

"In  the  year  1897  a  case  of  yellow  fever  was  officially 
returned  by  the  medical  officer  at  Cape  Coast. 

"In  the  year  1897  a  series  of  deaths  occurred  at  Saltpond 
and  Cape  Coast,  and  the  disease  there  presented  the  clinical 
manifestations  of  yellow  fever. 

"  In  1898,  4  deaths  occurred  in  the  first  six  months  amongst 
the  Europeans  at  Saltpond,  and  were  classed  as  pernicious 
remittent  fever. 


IVORY  COAST  87 

"In  1902,  2  cases  of  yellow  fever  were  recorded  at  Cape 
Coast  by  the  late  Dr  W.  Murray. 

"  In  1903  a  highly  suspicious  outbreak  occurred  at  Main- 
traim,  and  ended  in  6  deaths,  including  the  doctor,  whose  death 
unfortunately  precluded  the  possibility  of  any  medical  history 
being  rendered. 

"  Subsequent  to  this  the  only  occasion  on  which  cases  pre- 
sented a  suspicious  nature  was  in  1904,  when  Mr  A.  J.  Swanzy 
died  after  a  few  days'  illness,  having  presented  the  clinical 
symptoms  of  this  disease. 

"In  June  1905,  Mr  Wrenn  was  admitted,  and  died  within 
a  few  days,  after  showing  many  of  the  symptoms  of  this 
disease. 

"  Mr  Lulwer  died  in  the  hospital  on  24th  July,  after  dis- 
playing many  of  the  symptoms  of  yellow  fever. 

"  In  February  1906,  Mr  Jubb,  a  Wesleyan  missionary,  died  ; 
the  symptoms  pointed  to  yellow  fever. 

"On  14th  March  1906,  a  European  clerk  named  Bailey 
died  from  fever,  showing  symptoms  of  yellow  fever." 

References 

Elliott  (W.  M.) — "Yellow  Fever  in  West  Africa,"  Journal  of  Tropical 
Medicine,  July  1899. 

Browne  (S.  O.)— "A  Case  of  Yellow  Fever  at  Saltpond,  Gold  Coast," 
Journal  of  Tropical  Medicine,  1901  ;  The  Annual  Medical  and 
Sanitary  Reports  of  the  Gold  Coast;  The  Hospital  Case  Books;  The 
Quarterly  Medical  Reports  of  the  Troops  serving  in  West  Africa. 

BOYLE  (James) — A  Practical  Medico-historical  Account  of  the  Western 
Coast  of  Africa,  London,  1831. 

Bell  (John) — "  Surgeon  Royal  African  Corps,"  Report  on  Cape  Coast, 
1824;  "Medical  Reports  of  Troops  serving  upon  the  Gold  Coast"; 
Parliamentary  Return,  No.  544,  fuly  1864  ;  "  Mortality  of  Troops  at 
Cape  Coast,"  Return  No.  393,  June  1864;  "Mortality  of  Troops  at 
Cape  Coast,"  February  1882. 

Yellow  Fever  on  the  Ivory  Coast 

From  1 899- 1905  this  colony  shows  a  practically  unbroken 
record  of  genuine  malignant  yellow  fever.  So  bad  had  it 
become  at  one  time,  that  it  was  seriously  proposed  to  abandon 
Grand  Bassam,  and,  according  to  consular  and  medical  reports, 


S&  YELLOW  FEVER  IN  WEST  AFRICA 

the  greatest  hindrance  to  commercial  advance  in  the  past  has 
been  yellow  fever. 

In  1 899- 1 900  there  was  a  very  severe  epidemic. 

In  1903,  during  a  period  of  four  months,  no  steamers  entered 
the  port,  and  all  trade  was  at  a  standstill.  In  1904  the  disease 
was  again  prominent,  and  the  port  was  again  stated  to  be 
infected  in  1905.  In  fact, from  1900-1905,  a  year  has  not  passed 
without  the  report  of  cases,  and  "  gazette "  quarantine  notices 
have  appeared  in  regular  succession.  During  one  of  the 
epidemics,  50  per  cent,  of  the  native  population  left  Bassam. 
In  1903  the  European  population  was  about  60,  and  the  death- 
rate  amongst  these  was  50  per  cent. 

In  recent  years  drainage  and  specific  anti-mosquito  pre- 
cautionary measures  have  been  taken,  and  have  replaced  the 
old-time  process  of  disinfection  and  the  burning  of  houses.  It 
is  to  the  awakening-up  to  the  importance  of  specific  anti- 
Stegomyia  measures  on  the  Ivory  Coast,  and  in  Senegal,  and  in 
Togoland,  that  must  be  ascribed  the  immunity  from  yellow  fever 
which  these  colonies  have  experienced  since  1905. 

References 

Armstrong  (J.  P .)— Consular  Report  on  the  Ivory  Coast,  Foreign  Office, 

1905. 
Kermorgant  (A.)  —  "Maladies   epidemiques  qui   ont   regnees   dans   les 

colonies  francaises,  1900,  1902,  1905,  etc.,"  Annates  d'hygicne  et  de 

medecme  coloniales. 

Yellow  Fever  in  Togoland 

The  German  colony  of  Togoland,  since  it  has  been  opened 
up  to  commercial  enterprise,  has  been  the  seat  of  frequent 
outbreaks  of  yellow  fever.  Thus,  in  1896,40  cases  were  reported 
in  Klein  Popo. 

After  this  period  there  appears  a  lull,  that  is  to  say,  there  was 
no  obvious  outbreak  until  1905,  when  some  cases  were  recorded 
at  Anecho  and  Lome.  In  1906,  5  deaths  were  also  reported  at 
Lome,  and  1  case  at  Wydah.  Krueger  states  that  30  cases 
occurred    in    Togoland   from    April    to    May    1906.       As   the 


DAHOMEY  89 

symptomatology  and  post-mortems  of  many  cases  are  given, 
there  is  no  doubt  of  the  identity  of  the  disease.  According  to 
the  official  gazettes,  quarantine  was  declared  against  Togoland 
and  Lome  on  22nd  April  1905  ;  Agone  and  Grand  Popo  in  May 
1905  ;  and  against  all  ports  in  Togoland,  June  1906. 

Dr  Otto  was  strongly  of  opinion  that  the  disease  was 
endemic,  and  that  the  virus  had  been  kept  up  by  mild  cases  and 
recurrences.  Those  who  have  studied  yellow  fever  in  recent 
years  regard  this  as  the  most  rational  explanation  of  outbreaks 
or  sporadic  cases  of  yellow  fever. 

Otto  also  draws  attention  to  the  fact  that  many  of  the 
cases  of  yellow  fever  were  diagnosed  as  "  pernicious  fever  "  with 
"inflammation  of  the  kidney,"  "febris  malaria  continua 
perniciosa  nephritica,"  "  fever  and  heart  disease,"  etc.  Thus,  as 
in  British  colonies,  so  in  the  German,  there  can  be  no  question 
that  yellow  fever  has  passed  unnoticed  under  a  great  variety  of 
names.  Probably  no  disease  has  been  mistaken  for  so  many 
other  diseases.  In  my  opinion  this  has  in  large  measure  arisen 
from  the  universal  reluctance  to  admit  the  existence  of  the 
presence  of  yellow  fever  in  any  colony.  No  doubt  commercial 
interest  is  the  real  cause.  There  were,  however,  excusable 
reasons,  such  as  the  lack  of  any  miscroscopic  test,  as  in  malaria, 
and  the  fact  that  a  large  proportion  of  cases  bear  a  considerable 
general  resemblance  to  malaria.  It  is  for  these  reasons  that  the 
best  guide  to  diagnosis  in  parts  of  the  world  where  undoubted 
large  outbreaks  of  the  disease  have  occurred  is  the  presence  of 
the  Stegomyia  in  abundance.  This  is  the  case  in  German,  as 
well  as  in  the  British  and  French  West  African,  colonies. 

Vigorous  anti-stagnant  water  ordinances  have  been  intro- 
duced and  enforced  in  Togoland. 

Yellow  Fever  in  Dahomey 

Within  recent  years  Dahomey  has  been  the  seat  of  numerous 
recorded  outbreaks.  In  1905,  cases  occurred  at  Lome  and  at 
Agone,  where  several  deaths  took  place. 


90  YELLOW  FEVER  IN  WEST  AFRICA 

In  1906  an  outbreak  occurred  at  Grand  Popo.  In  the  same 
year  yellow  fever  was  present  in  Porto  Novo  and  Koonu,  and 
1 1  deaths  are  said  to  have  taken  place. 

It  is  very  generally  recognised  amongst  merchants  that  the 
coast  and  river  towns  in  Dahomey  and  Togoland  are  very  liable 
to  yellow  fever. 

Considering  that  these  towns  are  close  to  Lagos,  it  would  be 
exceedingly  strange  if  Lagos  should  have  been  free  of  yellow 
fever  in  this  period,  even  admitting  that  yellow  fever  was  not 
endemic  in  that  city.  It  was  obviously  liable  to  be  imported  at 
any  time. 

References 

Otto  (M.)— "Ueber  Gelbfieber  in  Afrika,"  Archiv.  /.  Schiffs.  u.   Tropen 

Hygiene,  1907,  xi.,  p.  147. 
Krueger    (L.)  —  "Die    Gelbfiebererkrankungen    in    Togo,"    Archiv.    f. 

Schiffs.  u.  Tropen  Hygiene,  1907,  x.,  p.  653. 

Yellow  Fever  in  Southern  Nigeria 

It  would  be  strange,  in  view  of  the  reasons  which  I  have  put 
forward  for  regarding  yellow  fever  as  endemic  in  West  Africa, 
if  a  colony  like  Southern  Nigeria,  where  the  prevailing  town 
mosquito  is  the  Stegomyia  calopus,  and  close  around  which  the 
existence  of  yellow  fever  has  been  officially  chronicled  during 
the  past  fifteen  years,  should  be  exempt  from  endemic  yellow 
fever.  I  am  of  opinion,  however,  that  yellow  fever  is  endemic,  and 
that,  in  all  probability,  as  in  other  colonies,  the  disease  has  long 
been  overlooked  and  mistaken  for  other  diseases.  Unfortun- 
ately, the  medical  records  which  have  been  kept  in  the  hospitals 
in  the  past  have  been  of  a  very  scanty  nature,  and  there  are  no 
careful  manuscript  records  of  the  diseases  prevalent  amongst 
the  troops  and  sailors  similar  to  those  which  have  been 
preserved  in  Freetown. 

There  has  been,  however,  a  strong  opinion  expressed  by 
many  of  the  experienced  traders  that  the  disease  which  has 
proved  rapidly  fatal  to  the  white  man  on  several  occasions,  and 


SOUTHERN  NIGERIA  91 

which  had  at  the  time  been  attributed  to  a  malignant  form  of 
malaria,  was,  in  all  probability,  yellow  fever.  This  view  is  much 
strengthened  by  the  outbreak  of  yellow  fever  which  took  place 
in  Bonny  in  1899,  and  by  the  undoubted  cases,  in  my  opinion, 
of  yellow  fever  which  occurred  in  Lagos  in  1893- 1894  and  again 
in  1905  and  in  1906. 

I  will  now  briefly  record  the  outbreaks  and  supposed 
outbreaks  of  the  disease  in  some  of  the  chief  towns  of  Southern 
Nigeria,  in  order  that  the  student  may  realise  why  I  consider 
yellow   fever   endemic    in    Southern    Nigeria    at    the   present 

time  : — 

Yellow  Fever  in  Southern  Nigeria 

Warri. — The  medical  officer  reports  that  a  tradition  exists 
that  there  was  a  yellow  fever  outbreak  at  the  European  factories 
about  the  years  i860- 1870. 

Calabar. — An  undoubted  case  occurred  in  the  years  1890- 
1891. 

Bonny. — 1873:  Several  deaths  were  recorded  which  might 
have  been  due  to  yellow  fever. 

In  1883  it  is  stated  that  an  outbreak  of  yellow  fever  occurred 
due  to  importation  from  Freetown. 

In  1 890- 1 89 1  a  very  serious  outbreak  is  recorded  of  what 
was  unquestionably  yellow  fever.  The  medical  officer,  Dr 
Parker,  was  certain  that  it  was  genuine  yellow  fever.  The 
description  of  the  symptoms  are  such  as  to  leave  no  doubt  as  to 
the  nature  of  the  disease.  The  disease  was  thought  by  some  to 
be  malignant  malaria,  and  was  attributed  to  the  pulling  down  of 
an  old  factory ;  others  maintained  that  it  was  introduced  in  the 
straw  and  litter  on  a  ship  coming  from  South  America. 

The  natives  were  not  affected.  There  were  1 1  cases  and  9 
deaths  amongst  the  population  of  15  white  men. 

Dr  A.  J.  Brown,  who  was  in  Bonny  at  the  time,  informs  me 
that  he  attended  two  of  the  cases.  The  symptoms  were  head- 
ache, pain,  great  prostration,  albuminuria,  yellowness,  persistent 
black  vomiting. 


92  YELLOW  FEVER  IN  WEST  AFRICA 

Dr  Parker,  who  was  the  medical  officer  at  the  time,  stated 
that  he  was  convinced  that  the  disease  was  yellow  fever. 

He  subsequently  contracted  the  disease  and  died. 

Dr  MacDonald,  Bonny,  has  furnished  me  with  notes  of  a 
suspicious  case  which  occurred  in  1909,  six  weeks  after  arrival  in 
Bonny.  The  diagnosis  at  the  time  was  "  gastritis  and  jaundice." 
No  malarial  parasites  were,  however,  found  in  the  specimens  of 
blood  which  were  repeatedly  examined. 

From  numerous  inquiries  which  I  have  made  there  can  be 
no  doubt  that  yellow  fever  occurred  in  Lagos  in  a  virulent  form 
from  1 894- 1 895.  Thus,  I  have  it  on  reliable  authority  that  17 
members  of  a  mission  arrived  from  England  in  Lagos  on 
13th  December  1893.  Of  these,  5  had  died  by  the  end  of 
January  1894.  In  addition,  a  resident  missionary,  and  the 
young  child  of  another  missionary,  had  also  died.  The  cases 
presented  the  classical  symptoms  of  yellow  fever.  According  to 
Ott,  cases  were  reported  at  Lagos  in  1896.  This  is  confirmed 
by  Dr  Hopkins  who  saw  2  cases  in  that  year. 

At  Sapele,  in  1898- 1899,  there  were  a  considerable  number 
of  suspicious  deaths;  and  in  1907  an  outbreak  of  a  severe  type 
of  fever  was  recorded  at  Widah. 

Examination  of  the  medical  notes  in  the  hospital  at  Lagos 
convinces  me  that  genuine  well-marked  cases  of  yellow  fever 
occurred  in  the  years  1902- 1905  ;  there  were  also  many  mild 
cases. 

The  symptoms  recorded  are  violent  headache  and  body 
pains,  high  temperature,  slow  pulse,  suppression  of  urine,  black 
vomit,  and  coma,  terminating  fatally.  In  1905  the  symptoms 
recorded  could  hardly  be  those  of  any  other  disease  but  yellow 
fever,  yet  the  diagnosis  made  at  the  time  included  "  fever  and 
gastritis"  and  "fever  and  morbus  cordis" — a  diagnosis  which 
Ott  also  states  was  made  in  Togoland.  I  am  therefore  strongly 
of  opinion  that  in  Lagos  one  of  the  causes  of  mortality  in  the 
past  has  undoubtedly  been  yellew  fever.  When  it  is  recollected 
how  little  is  known  of  the  fevers  amongst   the   60,000   native 


SUMMARY  93 

inhabitants  of  Lagos,  and  when  it  is  understood  that  by  far  the 
most  abundant  mosquito  is  the  Stegomyia,  it  is  not  unreasonable 
to  assume  that  the  natives  in  all  probability  suffer  from  a  mild 
type  of  yellow  fever,  and  that,  therefore,  yellow  fever  is  endemic. 
Further  evidence  in  favour  of  this  contention  is  furnished  by 
the  admitted  frequent  presence  of  yellow  fever  in  Dahomey  and 
Togoland  close  by  (see  these  colonies).  It  must  also  be 
recollected  that,  just  as  in  the  case  of  Sierra  Leone,  the  infected 
Stegomyia  were  not  destroyed  by  fumigation,  but  were  left  to 
propagate  the  disease. 

Summary 

I  think  I  have  brought  forward  sufficient  evidence  based 
upon  accurate  records,  clinical  and  historical,  written  by  men 
of  admitted  ability  and  experience  in  yellow  fever,  to  conclusively 
prove  that  yellow  fever  has  been  of  far  more  frequent  occurrence 
than  is  usually  supposed  on  the  West  Coast.  That,  in  fact,  it 
has  appeared  annually  over  a  very  large  number  of  years 
practically,  as  my  figures  show  for  the  last  hundred  years. 

A  few  gaps  of  a  few  years  have  occurred,  such  as  between 
1852  and  1858,  1868  and  1872,  1873  and  1878,  1878  and  1883, 
1884  and  1890. 

But  from  1890  to  the  present  date  I  am  of  opinion  from 
the  data  which  I  have  examined  that  there  is  an  unbroken 
line. 

During  the  whole  hundred  years  there  is  no  large  interval 
which  would  make  it  reasonable  to  suppose  that  yellow  fever 
had  completely  died  out  on  the  coast. 

In  my  opinion  this  evidence  is  so  strong  that  we  are  obliged 
to  assume  that  the  disease  is  endemic  upon  the  West  African 
coast  for  at  least  the  last  hundred  years. 

The  question  now  therefore  arises,  by  whom  has  the  virus 
been  kept  up  ? 

In  the  first  place,  we  know  positively  that  the  transmitting 
agent,  the  Stegomyiay  is  present  in  overwhelming  quantity.     It 


94  YELLOW  FEVER  IN  WEST  AFRICA 

only  remains  to  prove  how  a  continuous  source  of  infection  has 
been  maintained. 

To  those  who  would  adopt  the  theory  of  importation,  it  would 
mean  a  continuous  importation  from,  say,  the  West  Indies, 
Central,  or  South  America,  and  there  is  no  history  of  such 
importation. 

Therefore,  in  my  opinion,  the  most  reasonable  explanation 
is  the  one  which  has  proved  correct  in  the  West  Indies,  Central, 
and  South  America ;  and  is  adopted  by  the  most  recent  English, 
French,  and  German  investigators  in  yellow  fever,  namely,  that 
the  disease  exists  amongst  the  natives  in  a  mild  form  ;  in  other 
words,  that  it  is  endemic. 

A  little  consideration  will  show  that  the  whites  have  not 
been  the  source  of  the  continuous  infection  for  the  reason 
that  the  total  number  of  whites  on  the  whole  West  African 
coast  has  never  been  large  enough  to  admit  of  continuous 
keeping  up  of  the  virus ;  the  whites  are  in  the  very  small 
minority. 

Therefore,  precisely  as  in  the  case  of  the  sister  disease, 
malaria,  the  continuous  or  endemic  source  of  infection  is  the 
comparatively  dense  native  population  of  the  West  Coast. 

The  evidence  which  I  have  brought  forward  also  conclusively 
points  both  in  English,  French,  and  German  colonies  to  a  vast 
amount  of  mistaken  diagnosis.  Yellow  fever  was  not  suspected 
in  its  mild  form,  and  it  was  not  found  out,  it  was  only  discovered 
when  fatal  cases  made  their  appearance,  and,  as  my  evidence 
shows,  these  cases  were  as  often  as  not  mistaken  for  other 
diseases.  These  same  mistakes  in  diagnosis  have  occurred  over 
and  over  again  in  yellow  fever  countries,  especially  in  the 
commencement. 

I  therefore  conclude  from  the  evidence  that  a  comparatively 
large  number  of  deaths  and  mild  cases  have  occurred  from 
yellow  fever  in  the  past  and  which  have  been  attributed  to 
malaria,  chiefly  the  "bilious  remittent  fever."  Most  authorities 
upon  yellow  fever  are  agreed  that  in  a  very  large  number  of 


YELLOW  FEVER  YEARS 


95 


instances  "  bilious  remittent  fever  "  is  another  name  for  yellow 
fever. 

It  must  be  recollected  that  it  is  only  in  this  year  that  effective 
sulphur  fumigation  of  the  infected  Stegomyia  has  been  attempted 
on  the  West  Coast  after  outbreaks. 

Therefore  infected  Stegomyia  were  left  in  the  past  to  live  on 
and  to  carry  infection  into  a  succeeding  year. 

Finally : — 

(i)  The  historical  record  of  outbreaks  and  sporadic  cases,  as 
recorded  above ; 

(2)  Mistaken  diagnosis  ;  and 

(3)  The  absence  of  any  destruction  of  infected  Stego?nyia  in 
the  past,  is  evidence  overwhelmingly  in  favour  of  the  disease 
being  endemic  on  the  coast,  and  of  its  having  been  repeatedly 
mistaken  for  other  diseases  or  entirely  overlooked. 


Tears  in  which  Yellow  Fever  has  appeared  in  Sporadic  or 
Epidemic  Form  in   West  Africa 

Note. — These  figures  are  based  upon  documents,  official  reports,  and 
published  memoranda  carefully  examined  by  the  author. 


1807 

1826 

1894 

1809 

1827 

1844 

1878 

1895 

1828 

1845 

1862 

1896 

1829 

1846 

1863 

1897 

1812 

1830 

1847 

1864 

1865 

1898 
1899 

1814 

1866 

1883 

1900 

1850 

1867 

1884 

1901 

18 16 

1868 

1902 

1817 

1835 

1852 

1903 

1818 

1836 

... 

1904 

1819 

1837 

1905 

1820 

1838 

1872 

1906 

1821 

1839 

1856 

1873 

1890 

1822 

1840 

1891 

1908 

1823 

1841 

1858 

— . 

1909 

1824 

1842 

1859 

... 

1893 

1910 

1825 

PART    II 

SYMPTOMATOLOGY  AND   TREATMENT 


07 


G 


CHAPTER   VIII 

EXPERIMENTAL  YELLOW  FEVER  AND  YELLOW  FEVER  TYPES 

In  this  chapter  I  desire  to  draw  attention  to  the  various  types 
of  yellow  fever,  those  forms,  more  especially,  which  often  pass 
unrecognised  because  of  the  mildness  of  their  symptoms ;  but 
which  nevertheless  are  the  means  of  keeping  up  a  constant 
infection,  and  are  the  source  of  the  more  typical  severe  forms  of 
fever  which  attack  non-immunes  and  new  arrivals. 

The  study  of  infectious  diseases  teaches  us  that  until  we  are 
in  possession  of  some  simple  scientific  clinical  test,  such,  for 
example,  as  the  finding  of  a  protozoon  or  bacterium  in  the 
blood,  or  in  a  tissue,  or  until  we  possess  a  serum  reaction  as  in 
the  case  of  typhoid,  there  must  exist  immense  difficulty  as  to 
the  diagnosis  of  the  true  nature  of  any  disease  in  its  early 
stages. 

The  young  medical  officer  will  experience  this  difficulty  in 
deciding  what  is  and  what  is  not  yellow  fever.  The  same 
difficulty  crops  up  in  every  disease.  Were  we  in  a  position  to 
diagnose  early  the  very  mild  forms  of  typhoid,  scarlet  fever, 
diphtheria,  etc.,  the  prevalence  of  these  diseases  in  Europe  to-day 
would  be  far  different. 

In  the  majority  of  cases  a  diagnosis  is  not  made  until  the 
well-marked,  severe,  or  as  they  are  termed  "  classical "  signs 
of  the  disease  in  question  have  declared  themselves.  So  it  is 
with  yellow  fever. 

It  is  for  these  reasons  that  it  is  very  essential  to  study  what 
are  the  uncomplicated  symptoms  produced  by  the  bite  of  the 

90 


100    EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

Stegomyia,  and  then  to  analyse  and  see  if  in  nature  there  are 
diseases  which  present  similar  or  closely  similar  symptoms. 

I  have  endeavoured  to  bring  out  these  points  in  the  following 
account.  It  will  serve  as  an  introduction  to  those  more  severe 
symptoms  met  with  in  yellow  fever,  which  are  regarded  as 
"  typical  "  of  that  disease. 

It  is  a  golden  rule  in  analysing  any  disease,  to,  where 
possible,  direct  in  the  first  instance  attention  to  experiments  or 
direct  observations.  Unfortunately  a  large  number  of  tropical 
diseases  are  still  based  upon  a  most  hazy  and  inaccurate  patho- 
logical foundation. 

In  yellow  fever,  however,  thanks  to  the  experimental 
work  of  Finlay,  Reed,  Carroll,  and  other  American  observers,  we 
have  a  very  definite  foundation  to  build  upon. 

I. — Experimental  Yellow  Fever 

The  reason  why  the  Reed  Commission  did  not  hesitate  to 
make  direct  Stegomyia  inoculations  in  man,  was  because  as  they 
state,  Finlay  had  shown  as  the  result  of  90  inoculations  that 
little  danger  resulted  from  the  bites  of  infected  Stegomyia.  In 
other  words,  Finlay  found  that  in  18  per  cent  of  his  inoculation 
experiments  there  resulted  a  very  benign  form  of  yellow  fever. 
The  American  Commission  made  a  series  of  very  carefully 
recorded  observations,  and  in  12  cases  were  able  to  produce 
yellow  fever  in  its  milder  type.  The  following  are  some 
typical  examples : — 

CASE  V. — Infected  19th  January.  On  the  23rd  took  to  bed 
with  feeling  of  lassitude  and  headache  ;  temperature  99-2°;  pulse 
78.  Later  in  the  day  these  symptoms  increased,  and  were  severe 
headache,  chill,  eyes  and  face  flushed  ;  temperature  100  G ;  pulse 
104 ;  still  later  headache  increased  with  marked  backache, 
vomited  once;  temperature  103-6°;  pulse  no. 

At  the  end  of  42  hours  albumin  appeared  in  the  urine. 
The  sclerae  became  jaundiced  on  the  second  day,  and  by  the 
fourth  day  this  had  extended  to  other  parts  of  the  body. 


FlG.  6. — Temperature  and  pulse  curve 
(dotted  lower  curve)  from  an  experi- 
mental case  of  infection  by  the 
Stegomyia.  There  is  an  early  remis- 
sion in  the  temperature  curve  on  the 
second  day.  The  pulse  falls  from 
the  end  of  the  first  day,  and  does  not 
follow  the  temperature. — GuiTERAS. 


[To  face  X'-  100. 


STEGOMYIA  EXPERIMENTS  101 

The  symptoms  did  not  increase,  and  on  the  seventh  day  the 
temperature  was  normal. 

Diagnosis. — Yellow  fever  of  moderate  severity. 

Case  VI. — C.  W.,  American,  non-immune,  aged  twenty- 
seven,  with  his  full  consent  was  at  9.30  A.M.,  31st  January,  bitten 
by  two  of  the  three  mosquitos  that  had  been  applied  to  the 
foregoing  Case  V.  The  interval  that  had  elapsed  since  their 
contamination  was  therefore  51  days.  The  subject  remained 
well  until  12  o'clock  noon,  3rd  February,  when  he  complained 
of  heaviness  in  his  legs  and  some  supra-orbital  pain.  His 
temperature  at  this  hour  was  99°  F.  and  pulse  70.  At  1.30  P.M., 
it  had  risen  to  ioo°  F.,  and  at  5  p.m.  to  ioo-6°  F.,  and  pulse  to  84. 
The  primary  rise  of  fever,  which  was  somewhat  fluctuating  in 
character,  did  not  reach  its  height  until  at  the  end  of  24  hours, 
noon,  4th  February,  when  temperature  was  102-4°  and  the 
pulse  92.  The  facies  was  now  suggestive  of  yellow  fever. 
Remission  occurred  at  the  end  of  45  hours  and  lasted  for  about 
one  day.  The  secondary  rise  was  slight  in  character,  the  tempera- 
ture falling  to  normal  on  the  morning  of  the  sixth  day.  The 
case  was  very  mild  in  character.  Albumin  appeared  at  the 
end  of  75  hours  (beginning  of  fourth  day);  it  never  amounted 
to  more  than  a  distinct  trace  and  disappeared  on  the  eighth 
day.  There  was  no  occular  jaundice,  and  although  the  gums 
were  injected  and  swollen,  there  was  no  haemorrhage  at  any 
time.  The  patient  perspired  freely  throughout  the  attack. 
Convalescence  was  rapid.  The  subject  had  been  in  quarantine 
for  the  period  of  6  days  prior  to  inoculation. 

CASE  VII. — J.  H.,  American,  non-immune,  aged  twenty-six, 
with  his  full  consent  was  bitten  at  1 1  A.M.,  6th  February  1901, 
by  the  same  two  mosquitos  that  had  6  days  previously  bitten 
Case  VI.  Fifty-seven  days  had  therefore  elapsed  since  the  insects 
had  been  contaminated  by  biting  a  case  of  yellow  fever.  He 
remained  well  until  12  o'clock  noon,  9th  February,  when  he 
experienced  slight  chilly  sensations,  accompanied  by  yawning. 
At  this  hour  his  temperature  was  ioo°  F.  and  pulse  72.  At 
3  P.M.,  temperature  98-8°,  pulse  72.  Says  that  he  feels  "  out  of 
sorts"  but  has  no  headache.     At  5.30  P.M.  his  temperature  was 


102     EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

100-6°  F.,  pulse  78.  He  was  not  seen  until  7.30  p.m.,  when  he 
complained  of  backache  and  severe  general  headache,  more 
intense  through  the  frontal  region.  Eyes  much  injected, 
photophobia  very  marked,  face  flushed.  He  was  stretching  and 
yawning  constantly,  complained  of  nausea,  and  vomited  a  small 
quantity  of  partially  digested  food.  The  height  of  the  primary 
fever  was  reached  at  3  P.M.,  10th  February,  i.e.  22  hours  after 
the  commencement  of  the  attack,  when  the  temperature  was 
102-8°  and  the  pulse  98.  Remission  of  the  fever  to  99-4°,  and 
the  pulse  to  74,  occurred  at  6  A.M.,  nth  February,  making  the 
duration  of  the  primary  paroxysm  36  hours.  Twenty-four 
hours  after  the  remission  had  occurred,  the  temperature  had 
risen  to  102-4°  with  a  pulse  of  70.  The  fever  continued  to 
steadily  increase  until  midnight  of  12th  February,  when  a 
temperature  of  105°  F.  was  recorded,  with  a  pulse  of  90.  The 
subsequent  course  was  that  of  a  case  of  severe  yellow  fever. 
Slight  oozing  of  blood  from  the  gums  occurred  as  early  as  the 
third  day.  Ocular  jaundice,  beginning  on  the  third  day  became 
later  very  distinct,  and  was  associated  with  general  jaundice. 
Albumin,  however,  did  not  appear  until  the  sixth  day.  The 
fever  subsided  on  the  ninth  day,  and  was  followed  by  a  slow 
convalescence.  The  subject  had  been  in  strict  quarantine  for 
a  period  of  78  days  prior  to  inoculation. 

Cases   of    Yellow   Fever    Produced   by    the   Injection    of  Blood 
(Reed,  Carroll,  and  Agramonte) 

CASE  I. — W.  J.,  American,  non-immune,  aged  twenty-seven 
— in  quarantine  since  20th  December  1900 — with  his  full  consent 
at  n  A.M.,  4th  January  1 901,  was  injected  subcutaneously  with 
2  c.c.  of  blood  taken  from  the  general  circulation  of  a  case  of 
mild  yellow  fever  at  the  beginning  of  the  second  day  of  the 
disease  and  having  a  temperature  of  ioo-8°  F.  The  subject, 
who  had  been  in  strict  quarantine  at  the  station  for  a  period  of 
45  days,  remained  in  his  usual  health  until  the  early  morning  of 
8th  January,  when  he  complained  of  slight  frontal  headache. 
At  6  A.M.  his  temperature  was  98-2°  F.,  and  pulse  70 ;  9  A.M., 
temperature  98-8°  F.,  pulse  95  ;  frontal  headache  increased, 
with  slight,  chilly  sensations  in  the  feet  and  lower  extremities. 
There  was  some  congestion  of  the  eyes,  and  his   usual  florid 


INJECTION  EXPERIMENTS  103 

complexion  was  heightened  in  colour.  At  10.15  A-M-  tempera- 
ture 100-6°  F.,  pulse  97  ;  complains  of  some  pain  in  the  lumbar 
region.  At  11.20  a.m.,  temperature  101-4°  F.,  pulse  99.  The 
height  of  the  febrile  paroxysm  was  reached  at  3  P.M.  the  same 
day  when  the  temperature  was  103-4°  F.,  and  pulse  108.  The 
facial  expression  was  now  characteristic  of  yellow  fever.  The 
eyes  were  deeply  injected  and  watery  and  the  face  much 
suffused.  Photophobia  moderate,  frontal  headache  and  backache 
severe.  The  skin  was  moist.  The  remission  occurred  at  the 
end  of  24  hours — 9  A.M.,  9th  January — when  the  temperature 
had  fallen  to  99-4°  F.  and  the  pulse  86.  The  subsequent  history 
was  that  of  a  case  of  yellow  fever  of  moderate  severity.  Albumin 
was  found  in  the  urine  at  the  end  of  the  sixty-first  hour.  There 
was  some  bleeding  from  the  gums  on  the  third  day  and  moderate 
ocular  jaundice  on  the  fourth  day.  Fever  disappeared  on  the 
morning  of  the  seventh  day. 

Case  II. — W.  O.,  American,  non-immune,  aged  twenty- 
eight,  in  quarantine  since  20th  December  1900.  On  8th  January 
1901  at  9  P.M.,  with  his  full  consent,  he  was  given,  by  subcutane- 
ous injection,  1-5  c.c.  of  blood  taken  from  the  median  cephalic  vein 
of  Case  I.  just  12  hours  after  the  beginning  of  the  attack,  and 
when  the  temperature  was  102-4°  F- — that  is,  just  after  the  first 
febrile  paroxysm  began  to  decline.  The  subject  remained  in 
his  usual  condition  the  following  two  days. 

nth  January  1901. — Six  a.m.  his  temperature  was  98-9°  F. 
and  pulse  70.  He  complained  of  being  disturbed  by  dreams 
during  the  night  and  had  some  frontal  headache.  At  9  A.M. 
temperature  100°  F.,  pulse  77.  At  10.15  A.M.  temperature 
ioi-4°F.,  pulse  76.  Eyes  decidedly  congested  and  face  moder- 
ately suffused.  At  12  o'clock  noon,  when  the  temperature  had 
risen  to  103-2°  F.  and  the  pulse  102,  the  height  of  the  primary 
paroxysm  had  been  reached.  Headache  and  backache  were 
now  much  complained  of.  The  facial  expression  was  character- 
istic. The  remission  occurred  at  the  end  of  24  hours,  lasted  one 
day,  and  was  followed  by  a  very  moderate  secondary  fever.  A 
distinct  trace  of  albumin  was  found  in  the  urine  passed  at 
2  A.M.,  1 2th  January,  17  hours  after  the  attack  began.  A  few 
hyaline  casts  were  also  present.     Slight  bleeding  from  the  gums. 


104    EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

occurred  on  the  second  and  third  days  of  sickness.  The 
character  of  the  attack  in  this  case  was  very  mild.  The 
albumin,  which  at  no  time  amounted  to  more  than  a  distinct 
trace,  did  not  disappear,  however,  until  24th  January. 

CASE  III. — W.  F.,  American,  non-immune,  aged  twenty -three, 
was,  with  his  full  consent,  at  1  P.M.,  22nd  January  1901, 
injected  subcutaneously  with  0-5  c.c.  of  blood  taken  on  the  second 
day  from  the  general  circulation  of  a  severe  case  of  yellow  fever, 
which  was  fatal  on  the  seventh  day  of  the  disease.  The  patient's 
temperature  when  the  blood  was  withdrawn  was  1030  F.  and 
pulse  90°.  The  subject  remained  well  during  the  following  day, 
24th  January  ;  at  6  A.M.  his  temperature  was  98-4°  F.  and  pulse  78. 
He  partook  of  a  hearty  breakfast  at  6.30  A.M.  which  he  vomited 
soon  afterwards.  At  7  A.M.  he  complained  of  dizziness  and 
general  lassitude ;  temperature  98-4°  F.,  pulse  yS.  At  9  A.M. 
chilliness  complained  of,  but  there  is  no  record  of  temperature 
or  pulse.  At  9.30  A.M.  temperature  ioo-6°  F.,  pulse  82.  Frontal 
headache  well  marked.  Eyes  already  injected  and  face  slightly 
suffused.  At  10.30  A.M.  temperature  ioi-2°F.  and  pulse  86. 
An  hour  later  his  temperature  was  102-6°  F.  and  pulse  82.  The 
height  of  the  primary  paroxysm  was  reached  at  1  P.M.  when  the 
temperature  was  102-8°  F.  and  pulse  98.  At  this  hour  photo- 
phobia was  well  marked,  and  constant  complaint  made  of  severe 
frontal  headache  and  backache,  together  with  pains  in  the  lower 
extremities.  The  skin  was  moist  The  remission  occurred  at 
the  end  of  36  hours.  The  subsequent  course  was  that  of 
a  case  of  yellow  fever  of  moderate  severity.  With  the  return  of 
the  secondary  fever  there  was  present  sharp  backache  and 
headache.  Albumin  appeared  in  the  urine  at  the  end  of  57J 
hours.  Ocular  jaundice  was  present  on  the  third  day  and  there- 
after until  convalescence.  The  gums  did  not  bleed,  although 
they  were  swollen  and  injected.  Fever  subsided  on  the  sixth 
day,  and  albumin  disappeared  on  the  eighth  day. 

CASE  IV. — J.  H.  A.,  American,  non-immune,  aged  twenty- 
two,  with  his  full  consent,  received  subcutaneously,  at  12.15  p-M-> 
25th  January  1901,  1  c.c.  of  blood  taken  from  the  median 
cephalic  vein  of  Case  III.  just  27!  hours  after  the  commence- 
ment   of    the    latter's   attack    of   yellow    fever;    temperature 


INJECTION  EXPERIMENTS  105 

ioo-6°  F.  The  subject  remained  in  his  usual  condition  during 
26th  and  27th  January,  except  that  on  the  afternoon  of  the  last 
mentioned  date  he  complained  of  occipital  headache.  This  was 
present  on  the  following  morning,  28th  January ;  otherwise  he 
felt  well.  His  temperature  at  noon  was  98-6°  F.  and  pulse  6$. 
Occipital  headache  continued.  He  partook  of  dinner  with  fair 
appetite.  He  was  not  seen  again  until  3  P.M.  In  the  mean- 
while, at  1.1 5  P.M.,  the  patient  states  that,  while  sitting  alone  in 
his  tent,  he  began  to  feel  cold,  and  that  this  was  quickly  followed 
by  a  decided  chill  with  increase  of  headache.  He  noted  the 
hour  in  writing  at  the  time.  At  3  P.M.  his  temperature  was 
103-6°  F.  and  pulse  120.  The  eyes  were  intensely  congested 
and  face  deeply  suffused.  The  patient  was  very  restless,  and 
complained  bitterly  of  occipital  headache  and  backache.  Photo- 
phobia was  very  marked.  He  vomited  several  times  within  the 
next  2  hours.  Skin  hot  and  dry.  The  height  of  the  primary 
paroxysm  was  reached  at  3.30  P.M.,  at  which  hour  the  tempera- 
ture was  104-2°  F.  and  pulse  120.  The  subsequent  history  was 
one  of  severe  yellow  fever.  There  was  no  remission  of  the  fever 
until  the  fourth  day,  when  the  temperature  fell  to  ioi-2°F. 
Now,  for  the  first  time,  the  patient  ceased  to  complain  of 
occipital  headache  and  backache.  Albumin  appeared  at  the 
end  of  i8|  hours  (7.30  A.M.,  29th  January).  A  few  hyaline 
casts  were  also  present  at  this  time.  The  specimen  of  urine 
passed  at  6.40  A.M.,  30th  January,  contained  albumin  one- 
twentieth  by  volume,  and  many  fine  and  coarse  granular, 
bile-tinted  casts.  Ocular  jaundice  appeared  on  the  third  day. 
The  skin  of  the  face  and  of  the  anterior  part  of  the  neck  and 
thorax  was  tinted  on  the  fourth  day.  This  rapidly  became 
intensified  and  general.  The  secondary  fever  lasted  about  30 
hours,  the  temperature  falling  to  97-2°  F.  at  12  o'clock  (mid- 
night) of  the  fifth  day.  Marked  fluctuations  of  temperature 
continued  until  the  eleventh  day  of  illness.  Recovery  was 
slow  and  much  delayed  by  the  development  of  a  carbuncle 
in  the  left  sacral  region.  A  trace  of  albumin  was  still  present 
on  1st  March,  32  days  after  the  attack  had  begun. 

As  the  result  of  the  preceding  and  of  further  experiments,  it 
is  proved  that  during  the  first  three  days  of  illness,  the  blood  of 


106     EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

the  person  suffering  from  yellow  fever  contains  the  virus,  what- 
ever its  nature  may  be ;  that  the  Stegomyia  may  become  in- 
fected, and  may  transmit  the  virus  after  an  incubation  period  of 
at  least  twelve  days  to  a  non-immune.  Similarly  when  during 
the  three  first  days  of  illness  blood  was  withdrawn  and  injected 
into  a  non-immune,  fever  also  resulted,  as  is  shown  by  the 
preceding  experiments  of  Reed,  Carroll,  and  Agramonte. 

These  observers  also  showed  that  whatever  the  nature  of 
the  virus  it  could  pass  through  a  Berkefeld  filter,  for  the  filtrate 
when  injected  produced  an  attack,  and  the  blood  of  such  a 
case  when  inoculated  into  another  person,  also  produced  a 
reaction. 

It  has  also  been  shown  that  -i  c.c.  of  blood-serum  taken  on 
the  first  day  of  illness  from  a  case  of  yellow  fever  has  when 
inoculated  subcutaneously  induced  yellow  fever. 

References 
Experimental  Yellow  Fever 

Reed  (W.),  Carroll  (J.),  and  Agramonte  (A.)—"  Experimental  Yellow 
Fever,"  American  Medicine,  6th  July  1901  ;  Report  of  Working 
Party,  No.  2,  Yellow  Fever  Institute ;  Experimental  Studies  in 
Yellow  Fever  and  Malaria,  May  1904. 

GOLDBERGER  (J.) — Yellow  Fever,  Yellow  Fever  Institute,  July  1907. 

Reed  (W.),  Carroll  (J.),  and  Agramonte  (A.) — "The  Etiology  of  Yellow 
Fever,"  Journal  of  the  American  Medical  Association,  February 
1901  ;  "The  Etiology  of  Yellow  Fever,  A  Preliminary  Note,"  Pro- 
ceedings of  the  American  Public  Health  Association,  October  1900  ; 
"The  Etiology  of  Yellow  Fever,  A  Supplemental  Note,"  American 
Medicine,  February  1902. 

Report  of  Commission  of  Medical  Officers,  "  The  Cause  of  Yellow  Fever," 
Marine  Hospital  Service,  Washington,  1899. 

Carroll  (J.)  —  "History,  Cause,  and  Mode  of  Transmission  of  Yellow 
Fever,"  Journal  of  the  Association  of  Military  Surgeons,  1903. 

In  all  the  preceding  experimental  cases  the  Cuban  board  of 
yellow  fever  experts  had  no  doubt  about  the  nature  of  the 
disease  produced.  Yet  we  must  agree  that  the  symptoms  are 
very  mild,  and  not  very  specific.  Headache,  backache,  chill, 
lassitude,  a  rising  temperature,  the  pulse  not  following,  a  trace 


INFLAMMATORY  AND  ACCLIMATISING  FEVERS    107 

or  slight  albumin  in  the  urine,  occasional  vomiting,  jaundiced 
sclerae,  flushing,  gums  spongy,  and  showing  a  tendency  to  bleed, 
a  remission,  and  then  a  second  attack. 

These  are  certainly  not  symptoms  which  a  medical  officer 
would  pronounce  to  be  those  of  yellow  fever  unless  he  was  look- 
ing out  for  the  disease. 

The  great  authority,  Carroll,  has  stated  that  their  experiments 
show  that  genuine  yellow  fever  may  be  so  mild  in  character  that 
no  man,  no  matter  how  extensive  his  experience  may  have  been, 
would  dare  to  diagnose  it  as  such,  unless  he  knew  the  disease  to 
be  prevailing  at  the  time. 

Such  cases  appearing  at  the  beginning  of  an  outbreak,  would 
render  it  extremely  difficult  or  impossible  to  trace  the  origin  of 
the  severer  cases  occurring  later. 

In  the  light  of  the  above  precise  experimental  data  we  may 
then,  I  maintain,  be  prepared  to  find  that  yellow  fever  has  mas- 
queraded under  many  euphonisms,  as  the  following  shows  : — 

II. — Local,  "Endemial"  or  "Acclimatising" 
Fevers  of  Tropical  Towns 

Inflammatory  Fever,  Fievre  Inflammatoire 

The  "  inflammatory  fever  "  of  the  West  Indies  has  been  long 
recognised  as  an  acclimatising  or  seasoning  fever  which  new- 
comers were  expected  to  get.  It  was  another  name  for  some 
local  or  endemial  malady,  about  which  no  one  knew  any- 
thing precise,  except  that  all  were  expected  to  get  it  at  one 
time  or  another. 

The  older  writers  wrote  much  about  it,  and  held  that  it  did 
not  bear  any  strict  affinity  with  the  dreaded  yellow  fever.  The 
symptoms  recorded  were  lassitude,  chill,  injected  eyes,  flushing, 
fever,  pains,  frontal  headache,  lumbar  pain,  nausea,  vomiting, 
epigastric  tenderness,  urine  scanty  and  high  coloured.  These 
symptoms  might  become  more  marked,  headache  more  violent, 
also   the   epigastric  tenderness,  persistent   vomiting,  delirium, 


108    EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

elevation  of  temperature.  Later,  again,  marked  yellowness  of 
the  skin  might  set  in.  In  still  more  severe  attacks  persistent 
black  vomit  and  haemorrhages,  tarry  stools,  violent  delirium, 
coma,  and  death  occurred.  In  this  picture  of  the  inflammatory 
fever  of  the  West  Indies  the  reader  will  agree  there  are  the 
various  types  of  yellow  fever — the  mildest  to  the  most  severe 
forms. 

More  recent  writers  have  drawn  attention  to  this  disease, 
because  it  explained  the  recent  outbreak,  1909,  of  yellow  fever 
in  Martinique  and  Guadeloupe.  Most  of  our  knowledge  is  due 
to  Simond,  Aubert,  and  Noc,  who  have  been  engaged  on  more 
than  one  yellow  fever  investigation,  and  who  were  in  the  West 
Indies  when  I  was  there  last  year  on  yellow  fever  inquiries. 
These  investigators  show  that  the  symptoms  of  inflammatory 
fever  are  identical  with  those  of  experimental  yellow  fever. 
They  give  cases  where  a  mild  attack  of  inflammatory  fever 
passes  into  the  severe  form  of  yellow  fever.  The  symptoms 
can  be  so  mild  as  to  produce  only  an  "  embarras  gastrique." 

The  symptoms  are  usually  slight  fever,  vomiting,  albumin- 
uria, jaundice  on  the  fourth  or  fifth  day,  a  remission,  then  a  rise. 
The  disease  is  not  fatal,  nor  does  it  confer  absolute'  immunity. 
It  may  occur  quite  independently  of  any  case  of  severe  yellow 
fever  and  may  occur  in  epidemic  form ;  it  often  precedes  an  out- 
break of  malignant  yellow  fever,  but  it  may  not  do  so. 

They  conclude  that  under  inflammatory  fever  may  sometimes 
be  concluded  either  mild  cases  of  yellow  fever  or  cases  of 
malaria.  They  also  state  that  yellow  fever  is  characterised 
more  by  the  milder  symptoms  than  by  the  malignant. 

References 
Inflammatory  Fever 

Simond,  Aubert,  et  Noc— "  Contributions  a  l'etude   de  l'epidemiologie 

amarile,"  Annales  de  Pbistitut  Pasteur,  1909. 
Dickinson    (Nodes)  —  Observations    upon    the    Inflammatory    Endemic 

Incidental  to   Strangers  in  the   West  Indies,   com?nonly   called   the 

Yellow  Fever,  London,  18 19. 


"BILIOUS  REMITTENT  FEVER"  109 

As  in  the  case  of  experimental  yellow  fever  and  in  that  of 
inflammatory  fever,  the  patients  are  as  capable  of  giving  infection 
to  the  Stegomyia  as  virulent  cases  of  yellow  fever. 

There  can  be  no  doubt,  therefore,  both  from  the  evidence  of 
old  clinical  investigators,  as  well  as  of  modern  experimental 
investigators  that  this  endemial  acclimatising  or  seasoning  fever 
is  in  reality  very  often  genuine  yellow  fever,  and  is  the  source 
from  which  Stegomyia  becomes  infected.  Like  experimental 
yellow  fever,  it  would  be  overlooked  did  not  severe  types  of 
yellow  fever  occur  from  time  to  time. 

The  continuous  existence  of  inflammatory  fever  is  as  signifi- 
cant as  the  existence  of  severe  yellow  fever,  and  proves  that 
yellow  fever  is  endemic.  In  West  Africa  attention  has  more 
than  once  been  directed  to  inflammatory  fever. 

III. — Bilious   Remittent  Fever 

This  fever  takes  the  place  to  a  large  extent  in  West  Africa 
of  the  inflammatory  fever  of  the  West  Indies.  It  is  a  very  old 
name,  and  typified  the  "  acclimatising,"  "  seasoning "  or 
"  endemial  fever "  of  any  locality  which  newcomers  were 
expected  to  get.  Volumes  have  been  written  upon  it.  Some 
of  the  older  writers  held  that  just  as  in  inflammatory  fever,  it 
could  pass  into  severe  yellow  fever ;  others  held  that  it  was  a 
specific  entity. 

"  Borras  "  and  "febre  biliosa  "  of  Brazil.  —  The  majority  of 
large  tropical  towns,  in  Central  and  South  America  and  in  the 
West  Indies  have  each  had  their  own  special  local  or  acclimatis- 
ing fever.  It  is  most  significant  that  in  these  same  centres  of 
population, yellow  fever  was  the  disease  which  sooner  or  later 
attacked  the  newcomer.  We  further  know  that  the  Stegomyia 
was  the  common  mosquito  of  these  places.  In  Cuba  the  local 
fever  was  called  "Borras."  In  Brazil,  " febre  remittente  bilioso 
dos  pezos  quentes  "  or  "  febre  amarelle  dos  acclimatados."  The 
evidence  is  in  favour  of  these  being  mild  types  of  yellow  fever, 
common  amongst  the  native  inhabitants,  and  giving  them  the 


110     EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

necessary  immunity  against  the  severe  or  fatal  type.  There- 
fore, in  epidemic  times  they  escaped,  whilst  the  mortality  rate 
amongst  the  new  arrivals  was  appalling.  Examples  of  this  have 
been  recorded  at  Rio,  Santos,  Vera  Cruz,  Para,  Havanna.  Now, 
however,  thanks  to  anti- Stegomyz'a  measures,  natives  and  new- 
comers are  on  the  same  footing,  both  are  now  non-immunes, 
and  equally  susceptible. 

Some  of  the  older  observers  held  that  bilious  remittent 
fever,  carried  from  one  locality,  could  burst  out  into  the 
malignant  yellow  fever  on  arrival  in  another  country.  All 
these  doubts  and  theories  pointed  to  the  fact  that  the  older 
clinicians  were  observing  one  and  the  same  disease,  but  of 
different  types  of  severity.  From  the  investigation  of  careful 
records  of  outbreaks  of  yellow  fever,  there  can  be  no  other  con- 
clusion, than  that  by  the  name  bilious  remittent  fever  has  passed 
a  very  large  number  of  cases  of  genuine  yellow  fever. 

Bilious  remittent  fever  may  also  and  does,  just  as  inflam- 
matory fever,  include  a  proportion  of  malaria  cases,  but  it 
undoubtedly  has  very  frequently  been  used  as  another  name  for 
yellow  fever. 

For  example,  Colonel  Birt  in  a  recent  paper,  published  in 
the  Journal  of  the  Royal  Army  Medical  Corps ;  refers  to  the 
outbreaks  of  yellow  fever  in  Malta,  and  how  in  1881  there  are 
entered  69  cases  of  bilious  remittent  fever  with  6  deaths.  He 
points  out  that  primary  malaria  is  exceedingly  rare  in  Malta ; 
and  is  limited  to  one  remote  valley.  He  concludes  that  the 
term  "  bilious  remittent "  was  only  a  euphonism  for  yellow  fever. 
Carroll  refers  also  to  this  disease  in  the  following  decisive 
terms. :  "  We  know,  as  a  matter  of  fact,  that  here  in  the  United 
States,  yellow  fever  has  been  time  and  time  again  called 
'  bilious  remittent  fever,'  until  the  occurrence  of  a  number  of 
fatal  cases  with  black  vomit  proclaimed  the  true  nature  of  the 
disease.  There  is  good  reason  to  believe  that  with  the 
approaching  complete  control  of  yellow  fever,  the  old  time 
bilious  remittent  fever  will  become  much  less  frequent  in  the 


"BILIOUS  REMITTENT  FEVER"  111 

United  States."  Rush,  who  had  unique  experience  in  yellow 
fever  epidemics  in  the  United  States,  regarded  bilious  remittent 
as  yellow  fever.  Another  American  authority  in  describing 
the  great  epidemic  of  yellow  fever  at  Baltimore,  mentions  how 
it  commenced  with  a  long  series  of  bilious  remittent  cases. 
From  Horton's  description  of  bilious  remittent  fever  in  his  work 
on  the  tropical  diseases  of  warm  climates,  there  can  be  no  doubt 
that  he  is  describing  yellow  fever. 

Carroll  further  states  : — "  Recent  experiments  have  shown 
that  genuine  yellow  fever  may  be  so  mild  in  character  that  no 
man,  no  matter  how  extensive  his  experience  may  have  been, 
would  dare  to  diagnose  it  as  such,  unless  he  knew  the  disease  to 
be  prevailing  at  the  time."  Elsewhere  he  states  : — "  Bilious 
remittent  fevers,  epidemic  in  character  and  accompanied  by 
jaundice,  of  short  duration,  occurring  on  vessels,  in  seaport 
towns,  and  along  the  lines  of  travel  from  them,  are  closely 
related  to  and  probably  identical  with  yellow  fever." 

I  am  informed  that  as  a  matter  of  fact  bilious  remittent 
fever  has  largely  disappeared  from  the  Gulf  Ports  of  the 
United  States. 

In  an  official  report,  drawn  up  for  the  Marine  Hospital 
Service  in  the  United  States  in  1898,  the  following  statement 
occurs : — "  The  bilious  remittent  fever,  that  in  our  old  text 
books  of  medicine  occupied  such  a  conspicuous  place  in  tables 
of  differential  diagnosis  with  yellow  fever,  has  practically 
disappeared  from  the  Southern  Sea  border,  since  yellow  fever 
ceased  to  be  an  endemic  there.  It  was  in  fact  the  yellow  fever 
of  the  natives  and  of  places  in  the  interior."  This  is  a  most 
significant  statement,  for  it  shows  that  bilious  remittent  fever  has 
in  places  diminished  or  disappeared  pari  passu  with  yellow  fever. 

Of  course  the  malarial  forms  of  bilious  remittent  may,  and 
do  continue  to  exist. 

Pipe-borne  water  supplies  appear  to  have  affected  bilious 
remittent  fever,  precisely  as  they  have  done  yellow  fever. 

Let  us  now  examine  bilious  remittent  fever  in  the  light  of  old 


112    EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

and  recent  observations,  more  especially  as  it  affects  West 
Africa.  One  of  the  best  accounts  of  this  disease  will  be  found 
in  the  first  volume  of  the  British  Medical  Journal,  then  the 
Provincial  Medical  Journal,  1842,  by  E.  J.  Burton,  Surgeon  to 
the  Royal  African  Corps. 

He  classifies  the  fevers  of  West  Africa  into  (1)  bilious 
remittent  fever ;  (2)  simple  bilious  fever ;  (3)  "  intermittent 
fevers  "  ;  (4)  yellow  fever. 

With  regard  to  yellow  fever,  he  states  that  it  generally 
appears  in  epidemic  form  every  seven  years  in  Sierra  Leone. 
He  mentions  that  its  origin  had  given  rise  to  much  debate  :  some 
regarded  it  as  imported,  but  the  majority  were  of  opinion  that 
it  had  a  local  origin.  Burton  believed  in  the  local  origin,  and 
the  great  majority  of  writers  both  before  and  after  Burton's 
time  have  held  a  similar  opinion.  He  then  goes  on  to  state 
that  "  yellow  fever  has  been  considered  by  many  as  an  aggra- 
vated form  of  remittent  fever,  and  the  idea  is  supported  by  the 
fact  that  all  the  symptoms  are  similar,  only  much  more  severe 
in  the  former.  This  error,  however,  for  error  it  must  be 
considered,  originates,  I  am  led  to  think,  in  mistaking  the 
severer  types  of  bilious  remittent  for  yellow  fever,  and  it  must 
still  be  considered  that  the  latter  is  a  specific  disease— one,  in 
fact,  sui generis T 

Burton  describes  how  bilious  remittent  fever  or  "country 
fever  "  proves  fatal  every  year  to  a  large  number  of  people,  and 
how  every  year  it  appears  in  an  endemic  form.  It  can  never  be 
said  to  be  wholly  absent,  and  not  unfrequently  appears  in  the  dry 
season.  He  further  points  out  how  Boyle,  a  well-known 
authority  on  the  fevers  of  West  Africa,  proposed  to  divide  the 
endemic  bilious  remittent  into  : — 

(1)  Local  bilious  remittent;  and 

(2)  Climatorial  bilious  remittent. 

It  is  most  significant  to  note  that  Boyle  found  this  division 
necessary,  for  how  otherwise  could  he  explain  the  occurrence  of 
bilious  remittent  in  ships. 


"BILIOUS  REMITTENT  FEVER"  113 

So,  therefore,  he  proposed  the  name  "climatorial  bilious 
remittent "  for  those  cases  developing  on  ship  board  who,  not 
having  set  foot  on  land,  nevertheless  developed  the  fever.  This 
is  to  my  mind  the  most  striking  evidence  in  support  of  my 
contention  that  this  fever  is  none  other  than  yellow  fever. 

It  was  as  common  on  ships  in  the  nineteenth  century  as 
yellow  fever.  Naturally  it  was  because  it  always  has  been 
present  wherever  the  Stegomyia  is  found. 

Burton  gives  the  symptoms  as  follows  : — 

"  The  symptoms  are  extremely  varied,  and  scarcely  ever 
appear  in  the  same  order  in  any  two  persons  attacked.  There 
is,  however,  a  sufficiently  well-marked  similarity  in  all  cases  to 
lead,  after  a  little  experience,  to  an  immediate  and  correct 
diagnosis. 

"  Sometimes,  indeed  in  the  majority  of  cases,  the  disease  is 
ushered  in  by  a  sudden  chill,  generally  referred  by  the  patient 
to  the  small  of  the  back,  in  some  cases  extending  along  the 
whole  course  of  the  spine,  and  likened  to  the  trickling  of  cold 
water  down  the  back.  The  cold  feeling  just  described  some- 
times amounts  to  a  complete  rigor,  but  in  the  greater  number 
of  cases  the  chill  is  only  momentary,  and  at  other  times  no 
sensation  of  cold  whatever  is  felt.  The  rigor,  or  momentary 
feeling  of  cold,  as  the  case  may  be,  is  soon  followed  by  reaction  ; 
at  first,  alternate  flushes  of  heat  and  cold  are  perceived  ;  by 
degrees  the  skin  becomes  either  moderately  or  excessively  hot  ; 
if  the  latter  takes  place,  the  patient  feels  as  if  surrounded  by 
furnaces,  and  tosses  about  in  the  most  restless  manner.  There 
is  usually  a  dizzy  feel  of  the  head  from  the  beginning ;  but  as 
the  hot  fit  advances,  headache,  sometimes  of  the  most  excruciat- 
ing description,  sets  in ;  there  is  usually  a  feeling  of  stupor 
during  the  afternoon,  at  which  time  the  fever  is  at  its  height. 

"  The  disease  sometimes  commences  with  vomiting,  generally 
of  bile,  either  in  a  moderate  or  excessive  degree ;  but  there  is  at 
other  times  merely  a  degree  of  nausea,  and  in  some  cases 
neither  of  these  symptoms  appear.     At  the  beginning  there  is 

H 


114    EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

usually  a  ringing  sound  heard  in  the  ears ;  the  eyes  are  dull, 
and  more  or  less  sunken ;  the  conjunctivae  are  red,  and  appear 
injected ;  the  countenance  is  expressive  of  suffering  and 
anxiety ;  the  tongue  puts  on  different  appearances  in  most 
cases,  and  usually  forms  a  good  indication  as  to  whether  the 
disease  is  likely  to  prove  severe  or  otherwise ;  if  the  latter,  it  is 
at  the  beginning  of  the  fever  white  in  the  middle,  and  as  the 
disease  advances  it  becomes  coated  with  a  brown  fur ;  but  if  the 
tongue  is  red,  or  coated  with  a  white  tenacious  fur,  with 
extremely  red  edges,  then  a  severe  and  dangerous  attack  may 
be  apprehended.  Sometimes,  during  the  progress  of  a 
dangerous  attack,  the  tongue  becomes  dry  and  black.  No 
symptoms  portending  worse  consequences  than  this  can  show 
itself;  but,  happily,  even  under  such  discouraging  circumstances, 
the  case  is  not  to  be  considered  as  necessarily  fatal. 

"  There  is  usually  an  unpleasant  feeling  at  the  pit  of  the 
stomach;  sometimes  a  burning  sensation  is  complained  of;  in 
other  cases  it  amounts  to  a  feeling  of  pain,  especially  on 
pressure.  The  bowels  are  nearly  always  extremely  costive, 
though  the  disease  is  now  and  then  ushered  in  by  bilious 
dejections.  The  urine  is  high-coloured  and  scanty ;  in  some 
rare  cases  there  is  frequent  and  painful  micturition,  evidently 
depending  on  irritation  or  subacute  inflammation  of  the 
mucous  membrane  of  the  bladder. 

"The  thirst  is  in  most  cases  excessive;  some  patients  will 
swallow  gallons  of  fluid  in  the  course  of  the  twenty-four  hours. 
Pains  in  the  different  muscles  are  often  felt ;  but  few  cases  are 
unaccompanied  by  great  pain  in  the  joints,  and  those  of  the 
knees  seem  to  suffer  most. 

"  Sometimes  delirium  appears  in  a  few  hours  after  the 
commencement  of  the  attack.  There  are,  however,  few  patients 
who  pass  through  the  disease  without  being  more  or  less 
affected  with  this  disagreeable  symptom  at  some  period  of  the 
fever,  especially  during  the  night. 

"  When  it  occurs  only  at  night,  it  is  a  combination  of  delirium 


"BILIOUS  REMITTENT  FEVER "  115 

and  unpleasant  dreams,  extremely  annoying  and  fatiguing  to 
the  sufferer.  If  delirium  appears  during  the  day  it  is  fierce,  and 
attended  with  much  greater  excitement  and  mental  aberration. 

"  In  some  patients  the  disease  sets  in  suddenly  and  violently  ; 
sometimes  the  actual  period  of  invasion  cannot  be  ascertained 
with  any  degree  of  precision.  In  these  latter  cases  the  person 
feels  for  a  day  or  two  a  certain  degree  of  langour  and  lassitude, 
with  feebleness  of  the  lower  extremities,  especially  from  the 
knees  downwards,  and  partial  loss  of  appetite.  These  symptoms 
become  gradually  increased,  and  finally  so  aggravated  that  the 
patient  is  obliged  to  keep  his  bed,  and  a  regular  attack 
of  fever  sets  in. 

"  In  the  beginning  of  the  disease  there  appears  very  little 
alteration  in  the  pulse  ;  but  when  the  febrile  symptoms  become 
fully  developed,  it  is  either  quick,  full,  and  bounding,  or 
exceedingly  quick  and  hard  ;  at  other  times  it  is  only  accelerated 
and  full.  The  state  of  the  pulse,  however,  depends  more  on  the 
constitution  and  temperament  of  the  person  attacked  than  on 
the  comparative  severity  or  mildness  of  the  case." 

The  symptoms  described  may  appear  either  in  a  mild  form 
at  first,  and  afterwards  become  partially  or  greatly  aggravated, 
or  they  may  from  the  first  set  in  with  the  utmost  severity. 

In  some  cases  the  irritability  of  the  stomach  increases  to 
such  a  degree,  that  matter,  strongly  resembling  the  "  black 
vomit "  in  yellow  fever,  is  thrown  up,  and  frequently  a  yellow 
tinge  of  the  skin,  chiefly  about  the  neck  and  chest,  is  perceived. 
It  is  necessary  therefore  to  bear  in  mind  that  there  are  two 
ways  in  which  this  fever  commences. 

The  first  is  where  it  sets  in  with  violent  symptoms,  accom- 
panied by  great  heat  of  skin,  headache,  delirium,  etc. :  this  may  be 
denominated  the  tangible  form,  and  is  certainly  the  least 
dangerous,  if  promptly  and  energetically  treated. 

The  second  is  when  the  symptoms  are  all  more  or  less 
obscure,  there  is  but  slight  heat  of  the  skin  ;  when  the  hand  is 
applied  there  is  a  feeling  of  dryness  rather  than  heat.     There 


116     EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

is  a  constant  dull  pain  in  the  head,  scarcely  amounting  to 
headache ;  no  delirium  is  present,  but  there  is  slight  confusion 
of  ideas  during  the  night.  The  tongue  is  usually,  in  this  form 
of  the  fever,  red,  or  the  edges  are  very  red,  and  the  middle  of 
the  tongue  is  white ;  in  fact,  all  the  symptoms  of  fever  are 
present,  but  in  so  low  and  obscure  a  form  that  the  nature  of  the 
disease  might  be  mistaken  until  too  late.  This  is  decidedly  the 
most  dangerous  kind  of  fever,  and  may  be  called  the  obscure 
form. 

With  regard  to  the  remissions,  he  states  that  a  remission 
may  occur  or  the  type  may  be  continuous.  If  it  does  occur,  it 
appears  generally  on  the  third  day,  when  the  diminution  of 
symptoms  is  such  that  the  patient  feels  well  enough  to  rise  from 
bed. 

Burton  lays  stress  upon  a  very  significant  fact  in  connection 
with  bilious  remittent  fever,  namely,  the  generally  accepted 
doctrine,  with  which  he  agrees,  that  one  attack  of  the  fever 
confers  immunity  against  a  second  attack.  This  is  of  course 
of  great  importance,  because  it  points  to  a  disease  other  than 
malaria,  and  is  in  harmony  with  our  knowledge  of  experi- 
mental yellow  fever,  inflammatory  fever,  and  yellow  fever  in  all 
its  types. 

Burton  thus  describes  "  simple  bilious  fever." 

He  first  mentions  that  some  might  regard  it  as  a  milder 
form  of  the  bilious  remittent ;  he,  however,  was  inclined  to 
regard  it  as  a  specific  entity.  The  disease  is  ushered  in  with 
headache,  vomiting  of  bile,  fever ;  it  attacks  suddenly,  usually 
with  vomiting,  retching,  and  nausea.  In  the  majority  of  cases 
pain  in  the  head,  sometimes  very  severe.  Delirium  is  not 
common,  pulse  quick  and  full.  Tongue  coated,  urine  high- 
coloured,  sclerae  slightly  jaundiced. 

Returning  to  bilious  remittent  fever,  Burton  states  that  it  is 
the  endemial  remittent  fever  of  all  tropical  countries,  occasion- 
ally occurring  in  northern  climates  during  an  unusually  hot 
autumn. 


"BILIOUS  REMITTENT  FEVER  * 


117 


He  describes  it  as  met  with  in  the  West  Indies,  in  a  severe 
form,  in  the  East  Indies  in  a  mild  form.  It  causes  much 
mortality  in  British  Guiana  and  British  Honduras,  and  in  the 
southern  parts  of  the  United  States ;  it  has  appeared  in  an 
extremely  severe  form  in  some  of  the  Spanish  provinces. 

In  other  words,  with  the  single  exception  of  the  West 
Indies,  bilious  remittent  fever  has  been  common  wherever 
yellow  fever  has  been  present. 

He  then  states  that  of  all  countries,  it  is  most  severe  in 
West  Africa,  that  a  more  treacherous  fever  cannot  be  conceived. 
He  then  appends  the  following  tables,  drawn  up  by  Fergusson, 
for  the  troops  of  the  Royal  African  Corps  for  1825  : — 


Stations. 

Strength. 

Treated. 

Died. 

Deaths 
to  Cases 
Treated. 

Deaths 

to 

Strength. 

First  Quarter. 

Sierra  Leone . 
Gambia. 
Isles  de  Los  . 

138 
108 

Second  Quarter. 

Sierra  Leone  . 
Gambia. 
Isles  de  Los  . 

289 
140 
106 

46 
3 

5 

13 

2 

I    to  3-6l 

I   to  2-5 

r   to  22«2 

i  to  53 

Third  Quarter. 

Sierra  Leone. 
Gambia  . 
Isles  de  Los  . 

585 
108 

103 

386 
92 
99 

l6l 

74 
23 

1  to  2-39 
1    „    1-24 
1    ,,   4-3 

I  to    3-63 
1    •>    i'45 
1   >,   4-47 

Fourth  Quarter. 

Sierra  Leone  . 
Gambia. 
Isles  de  Los  . 

522 
112 

75 

146 

89 

120 

37 
60 

7 

1  to  3-94 
1    >.    1-47 
1    „I7-I 

I  to  14-1 
1    ,,    1-86 
1   „io-7 

From  the  above  table,  drawn  up  by  Surgeon  Fergusson  of 
the  Royal  African  Corps,  it  will  appear  that  in  a  regiment 
never  exceeding  796  men,  there  were  treated  in  one  year  986 
cases  of  fever,  and  of  these  cases  377  died,  giving  a  mortality 
of  nearly  one-half  the  total  strength  from  one  disease  alone. 

Although  authorities  might  be  multiplied  in  proof  of  the 
extremely  dangerous  and  fatal  nature  of  the  fever  in  question, 


118     EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

one  extract  only,  from  the  report  of  a  medical  officer  of  talent 
and  high  standing  in  the  service,  will  be  given. 

These  reports  were  made  about  sixteen  years  ago,  but 
recent  events  upon  the  coast  fully  prove  that  the  climate 
remains  the  same,  and  that  Europeans  cannot  approach  these 
regions  of  malaria  without  exposing  themselves  to  the  greatest 
danger. 

"  The  arrival  of  twelve  sergeants,"  says  this  officer,  "  forms  a 
striking  feature  in  the  events  now  under  consideration,  and 
affords  a  gloomy  illustration  of  this  deleterious  climate.  They 
were  selected  from  the  detachments  at  the  Isle  of  Wight ;  men 
of  good  character ;  their  conduct,  at  least,  when  on  this  coast, 
was  as  exemplary  as  could  be  expected  from  men  of  their  class 
in  society.  Some  irregularities,  of  course,  occurred ;  but  had 
they  been  sinners  above  all  sinners,  we  could  not  have  expected 
so  desolating  a  retribution. 

"  The  whole  of  them  were  attacked  with  fever,  and  within  a 
few  months  after  their  arrival,  eight  paid  the  debt  of  nature, 
and  only  one  at  present  (the  sergeant-major)  appears  fit  for 
duty.  The  constitutions  of  the  other  three  are  in  such  a 
shattered  state  that  plainly  indicates  an  advanced  stage  of 
visceral  disease.  The  sickness  and  mortality  amongst  their 
wives  and  children  are  nearly  in  the  same  proportion. 

"  This  affords  a  very  fair  specimen  of  what  may  be  expected 
from  the  effects  of  the  '  bilious  remittent  fever '  of  Western 
Africa,  without  taking  into  consideration  the  many  other  diseases 
which  attack  the  European  residents. 

"In  fact,  this  is  nothing  but  the  process  of  ' seasoning,' 
through  which  every  stranger  must  pass  in  a  few  months  after 
his  arrival  in  the  country." 

Impartially  reviewing  Burton's  descriptions  of  bilious 
remittent  fever  in  the  light  of  experimental  yellow  fever  and 
inflammatory  fever,  and  bearing  in  mind  that  Burton's  observa- 
tions were  long  before  the  Stegoniyia  doctrine,  or  the  discovery  of 
the  parasite  in  malaria,  one  is  forced  to  the  conclusion  that  by 
this  name  is  described  some  of  the  typical  types  of  yellow  fever. 


"BILIOUS  REMITTENT  FEVER"  119 

In  order,  however,  to  still  further  bring  home  the  fact  that, 
in  my  opinion,  under  the  term  "  bilious  remittent  fever,"  yellow 
fever  is  very  frequently  included,  I  adduce  the  following  further 
evidence. 

Boyle,  a  well-known  authority  on  tropical  fevers,  and  Naval 
and  also  Colonial  Surgeon  of  Freetown,  devotes  a  whole  chapter 
to  climatorial  bilious  remittent  fever. 

By  this  term  he  meant  a  fever  which  broke  out  on  ships  of 
the  type  of  bilious  remittent  fever.  This  is  very  significant, 
because  it  shows  the  great  difficulty  which  Boyle  had  in  con- 
ceiving why  bilious  remittent  fever  should  occur  spontaneously 
on  board  a  ship,  the  crews  of  which  had  not  been  ashore  for 
any  length  of  time. 

Naturally  it  is  the  old  story  of  yellow  fever  over  again ;  how 
to  explain  the  occurrence  of  yellow  fever  on  ships,  likewise  how 
to  explain  bilious  remittent  fever  on  ships.  It  would  be 
quite  impossible  to  explain  either,  unless  on  the  doctrine  of  the 
presence  of  the  Stegomyia. 

But  let  us  analyse  some  of  Boyle's  cases,  abstracted  from 
his  journal  on  board  the  H.M.S.  Cyrene  in  1822- 1823. 

CASE  I. — J.  J.,  seaman,  set.  thirty-five,  had  been  ashore  fourteen 
days  previous  to  sailing ;  taken  ill  with  headache  and  pains  in 
body,  fever  ;  pulse  90 ;  later  delirium.     Ended  fatally. 

Case  II. — J.  A.,  at  sea.  Symptoms: — Intense  headache, 
lassitude,  thirst,  fever,  pains  in  body,  nausea.     Recovery. 

Case  III. — S.  S.,  at  sea.  Severe  pain  in  head,  back  and 
loins,  weakness,  griping  and  purging,  fever.  Next  day  pulse 
reduced  in  frequency.     Recovery. 

Case  IV. — W.  H.,  on  board  a  schooner  at  Sierra  Leone. 
Symptoms  : — Intense  pain  in  head,  back,  and  loins,  fever,  pulse 
130,  vomiting,  great  thirst.  Later,  severe  vomiting  and  epi- 
gastric tenderness  developed,  stupidity,  pulse  and  temperature 
reduced.  Post-mortem  : — The  stomach  was  deeply  congested 
towards  pylorus. 


120    EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

Amongst  the  numerous  cases  of  bilious  remittent  fever 
which  developed  on  the  Cyrene,  there  occurred  one  case  of  fatal 
yellow  fever,  characterised  by  black  vomit  and  jaundice. 

Surely  this  case  gives  the  clue  to  the  origin  of  the  cases  of 
so-called  climatorial  bilious  remittent  which  occurred  on  board. 
Very  many  other  cases  are  given,  together  with  the  post- 
mortem findings,  and  there  cannot  be  a  doubt  that  they  were 
genuine  malignant  yellow  fever  cases  as  well  as  milder  types. 
These  cases  occurring  side  by  side  with  fatal  cases,  which 
were  either  diagnosed  at  the  time  as  yellow  fever,  or  which, 
from  the  description  of  the  post-mortems,  I  have  no  doubt 
were  yellow  fever,  is  unmistakable  evidence  of  the  yellow  fever 
nature  of  the  climatorial  bilious  remittent  fever. 

Boyle  then  devotes  a  chapter  to  his  local  bilious  remittent 
fever,  and  here  again  it  is  abundantly  evident  that  he  is  dealing 
with  one  of  the  common  mild  types  of  yellow  fever. 

He  describes  it  as  the  acclimatising  fever  of  the  locality, 
which  every  newcomer  had  to  get.  He  lays  particular  stress 
upon  the  fact  of  the  exclusive  predisposition  of  the  English 
and  Northern  races  to  the  disease.  The  symptoms  are  chill, 
malaise,  pain  in  head  and  body,  fever,  bilious  vomiting,  con- 
gested eyes,  yellowness  of  skin  and  eyes.  In  some  cases  tarry 
stools  and  dark  vomit,  delirium. 

He  then  notes  how  sporadic  cases  of  yellow  fever  break  out, 
and  he  calls  them  aggravated  cases  of  the  endemic  bilious 
remittent.  So  here  again  it  is  clear  that  we  are  dealing  with 
one  and  the  same  disease,  viz.,  yellow  fever. 

Boyle  gives  pages  of  description  to  this  endemial  remittent 
fever,  and  it  is  clear  that  it  passes  insensibly  into  the  epidemic 
form  or  yellow  fever. 

The  evidence  of  Surgeons  Barry,  Lawson,  Fergusson,  Tidlie, 
Burnett  and  many  others,  given  either  in  books  or  in  MS. 
records,  all  points  to  the  one  conclusion  :  that  cases  of  bilious 
remittent  fever  and  yellow  fever  occurred  together.  When  the 
fever   appeared  in   epidemic   form   or   accompanied   by   black 


"REMITTENT  FEVER"  121 

vomit,  it  was  called  yellow  fever,  otherwise  it  remained  simply 
climatorial  or  endemic  remittent  fever  —  a  repetition  of 
the  picture  of  "  inflammatory  fever "  in  the  West  Indies :  all 
degrees  of  severity  from  "  embarras  gastrique "  to  yellow 
fever. 

All  authorities  were  agreed  that  the  native  very  rarely 
suffered  from  the  severe  black  vomit  type,  and  they  also  observed 
that  the  bilious  remittent  gave  a  certain  degree  of  immunity 
against  yellow  fever.  Now  to  turn  to  the  recent  evidence 
furnished  by  the  1910  epidemics. 

In  the  first  place,  at  the  commencement  of  the  outbreak  of 
yellow  fever  in  Secondee,  came  a  stout  denial  on  the  part  of  the 
Press  and  some  of  the  medical  men,  that  yellow  fever  existed 
or  even  could  exist  on  the  coast. 

They  seriously  declared  that  the  disease  was  only  the 
malignant  form  of  bilious  remittent  fever  with  which  they  were 
well  acquainted,  and  which  usually  attacked  persons  towards 
the  rainy  season.  This  statement  is  quite  true,  if  it  is  accepted 
that  the  bilious  remittent  fever  is  true  yellow  fever  and  has,  as 
the  newspapers  state,  been  no  doubt  present  every  year. 

I  have  carefully  examined  a  large  number  of  case-books  and 
other  records  at  Secondee,  Accra,  Cape  Coast,  Saltpond,  Elmina, 
Axim,  Quittah,  Lagos,  and  Freetown,  and  I  have  found  that 
amongst  the  cases  returned  as  yellow  fever,  there  were  others 
diagnosed  as  bilious  remittent  fever  or  simply  remittent  fever. 

At  Lagos  I  was  particularly  struck  by  the  very  large  number 
of  remittent  cases.  Of  course  a  certain  proportion  of  these  are 
in  all  probability  malarial,  but  with  equal  certainty  we  can  say 
that  a  proportion  are  mild  cases  of  yellow  fever. 

It  is  beyond  dispute,  then,  that  during  outbreaks  of  well- 
marked  black  vomit,  there  have  occurred  in  the  present  year  and 
in  past  years  numerous  cases  of  "  remittent "  and  "  bilious 
remittent  fever."  This  is  not  a  new  observation  peculiar  to  the 
West  Coast :  the  same  fact  has  been  observed  wherever  yellow 
fever  has  been  present. 


122     EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

I  will  now  give  an  example  of  one  of  the  cases  of  yellow 
fever  which  occurred  in  Secondee  during  the  recent  outbreak. 
The  history  and  symptoms  of  the  case  were  : — 

Mr  D.  had  been  in  the  colony  a  few  months  on  this  occasion, 
but  had  been  on  the  coast  before.  Taken  suddenly  ill,  19th  May  ; 
21st  May,  vomited,  severe  headache,  temperature  1010,  jaundice, 
no  albuminuria  ;  22nd  May,  temperature  1020,  jaundice  deepened, 
conjunctivas  congested,  urine  scanty,  no  albumin ;  23rd  May, 
temperature  1020,  albumin  present  in  the  urine,  vomited  material 
like  beef-tea  dregs;  24th  May, temperature  103-4°, urine  scanty, 
very  albuminous,  jaundice,  pulse  70,  vomits  speckled  with 
black  spots  ;  25th  May,  temperature  ioi°,  restless,  urine  scanty  ; 
26th  May,  temperature  98-8°,  pulse ,80,  urine  loaded  with  albumin, 
scanty,  vomited,  petechiae  present  on  belly,  jaundice  deep, 
hiccough ;  27th  May,  temperature  98-8°,  pulse  feeble,  urine 
suppressed,  haemorrhage  from  mouth,  death. 

Post-mortem. — Surface  of  body  yellow,  petechiae,  liver  yellow 
and  congested,  recalling  the  appearance  of  nutmeg  liver,  neck 
of  the  gall  bladder  deeply  congested.  Stomach  contained  a 
copious  quantity  of  black  gramous  material,  also  the  intestines, 
"  stomach  and  intestines  stained  dark."  There  can  be  no  doubt 
about  this  case  belonging  to  the  severe  type  of  yellow  fever. 
It  was  one  of  several  that  occurred  one  after  the  other,  but 
nevertheless  a  native  medical  man  comes  forward  and  states 
as  follows : — 

"  The  case  of  the  late  Mr  D.,  whose  autopsy  I  witnessed 
yesterday,  was  one  of  malignant  bilious  remittent  fever,  and  not 
one  of  the  true  pestilential  yellow  fever.  That,  therefore,  all  the 
preceding  cases  which  were  on  all  fours  with  Mr  D.'s  case  were 
malignant  bilious  remittent  fever  and  not  yellow  fever." 

This  is  the  comment  of  a  medical  man  who  is  not  an 
exception  ;  he  is  an  example  of  many  who  go  about  encouraging 
the  belief  that  yellow  fever  does  not  exist.  It  is  of  course 
clearly  obvious  that  this  attitude  proves  that  malignant  bilious 
remittent  fever  is  only  yellow  fever  under  another  name. 

We  may  conclude,  therefore,  that  the  bilious  remittent  fever 


* REMITTENT  FEVER"  123 

of  West  Africa  is,  in   a  very  large  number  of  cases,   genuine 
yellow  fever  in  its  various  degrees. 

Additional  note  on  remittent  fever. — Careful  examination  of 
the  account  of  fevers  in  West  Africa  for  the  past  hundred  years 
up  to  the  present  day,  shows  the  extremely  ill-defined  position 
which  bilious  remittent  and  remittent  fevers  occupy.  To  this 
day  they  are  regarded  as  local  in  origin,  the  product  of  the 
coast,  in  other  words  endemic. 

Some  medical  men  would  say  that  they  are  the  result  of 
infection  by  anophelines,  that  is  that  they  are  malarial ;  but 
others  again  would  point  out  that  very  frequently  no  malarial 
parasites  are  found  in  the  blood,  and  that  therefore  they  must 
have  another  origin. 

But  there  are  very  few  who  take  into  consideration  the 
possibility  of  some  of  the  cases  being  due  to  infection  by  the 
Stegomyia,  that  is  that  they  may  be  in  fact  mild  forms  of  yellow 
fever.  If  the  view  is  correct,  it  accounts  for  the  difficulty  which 
the  older  clinicians  experienced  in  differentiating  between 
remittent  and  yellow  fever. 

The  history  of  an  epidemic  shows  that  very  often  an  out- 
break of  yellow  fever  was  preceded  by  an  outbreak  of  remittent 
and  bilious  remittent  fevers.  Medical  officers,  moreover,  often 
described  remittent  fever  ending  fatally  with  symptoms  of 
typical  black  vomit.  In  every  outbreak  of  yellow  fever  they 
discuss  the  relationship  of  the  one  disease  to  the  other,  and  even 
go  so  far  as  to  point  out  that  an  attack  of  remittent  fever  confers 
a  certain  degree  of  immunity  against  yellow  fever  (Burton). 

In  1837  Fergusson  describes  how  in  1836  the  barque  Mary 
arrived  at  Freetown.  In  fifteen  days  the  whole  of  the  crew 
were  attacked  with  endemial  remittent  fever.  Of  the  15  attacked 
10  recovered  and  5  died.  Fergusson  adds  that  the  disease 
was  not  accompanied  by  black  vomit ;  but  shortly  afterwards 
another  ship  arrived,  the  Lady  Douglas,  and  several  of  the  crew 
died  with  the  severe  symptoms  of  yellow  fever.  About  the 
same  time  the  H.M.S.   Curlew  sailed  from   Freetown    for   the 


124    EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

Gambia,  and  her  crew  went  down  with  malignant  remittent 
fever.  On  arrival  at  Bathurst  the  disease  developed  in  its 
typical  malignant  yellow  fever  form. 

Fergusson  states  how  the  yellow  fever  outbreak  in  1837  in 
Freetown  died  down  and  "  was  succeeded  by  the  common 
remittent  fever  "  ;  but  to  everyone's  astonishment,  the  malignant 
symptoms  again  made  their  appearance  after  a  few  months' 
apparent  cessation,  and  again  the  whole  of  a  ship's  crew  is 
reported  to  have  died  of  malignant  remittent. 

In  subsequent  years  the  military  reports  contain  frequent 
references  to  remittent  fever  ending  fatally  with  all  the  clinical 
symptoms  of  yellow  fever  ;  it  is  also  mentioned  how  closely  they 
resembled  yellow  fever,  and  how  frequently  they  occurred  in 
ships'  companies.  In  other  cases,  again,  half  the  cases  are 
diagnosed  as  remittent  and  the  remainder  as  yellow  fever 
cases. 

Staff-surgeon  Lawson  mentions  how  in  1847,  I2  whites  died 
from  yellow  fever  and  5  from  remittent  fever,  and  how  the 
disease  first  started  as  the  ordinary  local  remittent  form  and 
these  developed  into  the  malignant. 

It  is  a  well-known  observation  that  frequency  of  the  occur- 
rence side  by  side  of  bilious  remittent  or  remittent  fevers  and 
yellow  fever  both  on  land  and  on  ships.  Remittent  fever  was  a 
"  ship's  fever,"  as  much  as  yellow  fever.  Furthermore,  the 
remittent  fevers  have  appeared  at  places  where  there  was  no 
endemic  malaria  there. 

Blair  draws  attention  in  his  tables  to  this  prevalence  of 
remittent  fever  side  by  side  with  yellow  fever  in  Barbados, 
where  we  know  there  are  no  anophelines. 

Thus  out  of  a  garrison  of  2310,  in  the  year  18 16,  there 
occurred  470  cases  of  remittent  and  705  cases  of  yellow  fever, 
whereas  only  36  cases  of  intermittent  fever  are  recorded,  which 
latter  were  in  all  probability  imported  cases. 

In  West  Africa  the  case  is  similar,  whilst  no  doubt  a  con- 
siderable certain  number  of  cases  of  remittent  fever  are  malarial. 


"REMITTENT  FEVER 


125 


On  the  other  hand,  the  evidence  is  very  strong  that  a  certain 
number  of  them  are  genuine  cases  oi'Stegomyia  fever,  i.e.,  yellow- 
fever,  and  that  both  whites  and  blacks  are  liable  to  it,  but 
especially  the  former. 

Remittent  fever  on  the  Gold  Coast. — A  return  of  diseases 
under  the  heading  of  malaria  furnished  by  the  hospitals  at 
Accra,  Cape  Coast,  Elmina,  Axim,  Kwitta,  Secondee,  and 
Comassi  furnishes  the  following  results  : — 


Year. 

Remittent 
Fevers. 

Intermittent 
Fevers. 

1904 
1 90S 
1906 

241 
231 
273 

235 
161 
225 

A  return  on  the  same  lines  from  the  Gold  Coast  Colony,  Ashanti, 
and  the  northern  territories  gives  in  1907  a  total  of  1104  cases 
of  remittent  fever  and  1223  cases  of  intermittent  fevers  treated. 
Remittent  fever  in  Sierra  Leone. — Examination  of  the  cases 
admitted  into  the  Missionary  Home  at  Freetown  (for  whites 
only)  shows  a  very  considerable  number  of  cases  diagnosed  as 
remittent  fever,  and  one  or  two  cases  of  bilious  remittent  fever 
each  year.     The  figures  for  remittent  fever  are  : — 


1902 

16 

1903 

29 

1904 

34 

1905 

32 

1906 

21 

Remittent  fever  in  Southern  Nigeria. — Here  also  examination 
of  hospital  case-books  shows  very  large  entries  under  the 
heading  of  remittent  fever.  This  is  especially  noticeable  at  the 
Lagos  Hospital. 

In  view  of  what  has  already  been  said  concerning  remittent 
fevers,  the  question  remains :  Are  all  these  cases  of  remittent 
fever  malarial  ?     Or  may  not  a  considerable  portion  of  them  be 


126    EXPERIMENTAL  YELLOW  FEVER  AND  TYPES 

due  to  the  Stegomyia  ?  For  it  must  always  be  remembered  that 
the  Stegomyia  is  the  most  common  mosquito,  and  that  precisely 
similar  returns  of  remittent  fever  were  furnished  by  places  where 
there  were  no  anophelines,  and  where  therefore  the  remittent 
fever  must  have  been  due  to  the  Stegomyia,  which  we  know  was 
abundant. 

It  is  now  incumbent  upon  medical  officers  to  bear  these 
facts  in  mind,  and  to  endeavour  to  divide  the  remittent  and 
bilious  remittent  fevers  into  those  which  are  genuine  cases  of 
malaria,  and  those  which  by  exclusion  may  be  classed  as 
Stegomyia  fevers. 

Another  interesting  point  to  observe  will  be  :  whether  a 
reduction  in  bilious  remittent  and  remittent  fevers  will  follow 
the  putting  into  practice  of  rigorous  anti- Stegomyia  measures. 

On  going  over  records  of  the  health  of  our  troops  in  the  West 
Indies  and  other  stations,  it  is  very  clear  that  remittent  fevers 
and  yellow  fever  occurred  and  disappeared  together. 

The  great  authority  upon  yellow  fever,  Bancroft,  held  strongly 

the  view  that  remittent  fever  and  yellow  fever  had  a  common 

origin. 

References 

Second  Report  on  Quarantine,  London,  1852. 

Blair  (Daniel) — Some  Account  of  the  Yellow  Fever  Epidemic  of  British 

Guiana,  London,  1850. 
Burton   (E.  J.) — "  Observations  upon  the  Climate   and   Diseases   of  the 

British  Colonies  in  Africa,"  Provincial  Medical  Journal,  vol.  i.,  1843. 
Boyle  (James) — Account  of  the  Fevers  of  Western  Africa,  London,  1831. 
Pym  (Sir  William) — Yellow  Fever,  and  a  Report  upon  the  Diseases  of  the 

African  Coast  by  Drs  Burnett  and  Bryson,  London,  1848. 
VElTCH  (James) — A  Letter  on  the  Non- Contagious  Nature  of  Yellow  Fever, 

London,  1818. 
Rush   (B.) — Inquiry  into  the  Causes  of  Bilious  and  Intermitting  Fevers^ 

Philadelphia. 
HORTON   (J.   A.   B.) — Diseases  of  Tropical  Climates  and  their  Treat?nent, 

Edinburgh,  1874. 
DURHAM  (H.  E.) — Report  of  the  Yellow  Fever  Expedition  to  Para,  1902, 

Memoir  VII.,  Liverpool  School  Trop.  Med.,  1902. 


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CHAPTER   IX 

THE   CLINICAL   HISTORY   OF   VARIOUS   EPIDEMICS   OF 
YELLOW   FEVER 

Symptomatology  of  Yellow  Fever :  General 

Under  experimental  yellow  fever,  inflammatory  fever,  and 
bilious  remittent  fever,  I  have  already  described  very  many  of 
the  symptoms  of  yellow  fever.  The  point  to  bear  in  mind  in 
yellow  fever  is  the  wide  range  of  symptoms,  from  an  "  embarras 
gastrique "  and  feeling  of  lassitude  to  the  severe  symptoms 
culminating  in  black  vomit  and  suppression  of  urine. 

The  symptoms  usually  commence  with  a  chill  and  feeling  of 
lassitude,  headache,  lumbar  and  joint  pains,  which  become  more 
intense.  The  temperature  is  above  normal,  and  continues  to 
rise  from  twenty-four  to  forty-eight  hours,  reaching  104-5°  or  even 
higher,  but  not  usually.  The  temperature  may  continue  for 
four  or  five  days  more,  with  slight  variations,  or  as  may  happen, 
there  is  a  remission,  or  the  temperature  curve  may  present 
several  remissions.  The  pulse  is  that  of  any  fever,  it  is  quickened 
100  to  begin  with,  but  as  the  fever  progresses  the  pulse  slows 
down  to  90,  80,  70,  or  65,  or  even  lower,  whilst  the  temperature 
may  stand  at  ioo°,  102°,  or  104°. 

This  want  of  accord  between  pulse  and  temperature,  although 
by  no  means  constant,  is  exceedingly  characteristic,  and  serves 
to  stamp  the  disease  as  very  suspicious  of  yellow  fever.  It  is 
known  as  Faget's  sign.  The  tongue  is  coated  in  the  centre 
and  the  edges  and  tip  are  red.     The  gums  are  sore,  and  often 

127 


128     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

present  a  fine  red  line  of  congestion  where  the  lead  line  is 
usually  found. 

Nausea  and  vomiting  may  commence  very  early.  At  first 
the  contents  of  the  stomach,  then  thin  mucus,  or  bile-stained 
mucus,  then  on  the  fourth  or  fifth  day,  or  even  earlier,  small 
black  specks,  are  observed  in  the  vomit.  Subsequently  the 
typical  black  vomit  sets  in,  or  blood  may  be  vomited.  The 
stools  are  now  often  tarry. 

The  urine  is  a  febrile  one  to  commence  with,  then  after  the 
end  of  forty-eight  hours  or  later  a  trace  of  albumin  is  usually 
found.  This  increases,  and  at  the  same  time  the  urine  diminishes 
in  quantity,  and  finally  may  end  in  total  suppression. 

Yellow  discoloration  usually  sets  in  about  the  third  day, 
and  is  first  noticed  in  the  sclerae,  then  it  spreads  to  the  rest  of 
the  body.  It  is  characteristic  to  observe  the  deepening  of  the 
colour  as  the  disease  progresses.  Or  the  yellow  colour  may 
not  appear  till  after  death,  or  during  the  death  agony.  When 
once  seen  this  symptom  can  never  be  forgotten. 

Congestion  of  the  eyes  and  of  the  upper  part  of  the  body  is 
often  seen  early  and  petechiae  may  appear.  Haemorrhages  are 
common  from  the  nose,  mouth,  and  other  orifices. 

The  remission,  referred  to  above,  may  last  for  several  hours,  and 
very  often  gives  a  false  sense  of  security.  I  have  noticed  it  many 
times,  and  it  is  a  characteristic  and  suspicious  sign.  The  patient 
feels  well,  wants  to  get  up  and  take  a  meal.  It  is  succeeded  by 
a  relapse  and  the  temperature  rises.  This  is  sometimes  known  as 
the  second  paroxysm,  or  the  reactionary  fever. 

To  sum  up — yellow  fever  may  be  described  as  a  continuous 
fever  of  one  paroxysm,  lasting  more  than  twenty-four  hours. 
The  onset  is  sudden  and  accompanied  by  violent  headache, 
pain  over  the  eyes  ;  eyeballs  tender  to  pressure  ;  violent  pain  in 
the  back  {coup  de  bar  re) ;  epigastric  tenderness  ;  anorexia  ;  nausea 
and  vomiting.  This  is  sometimes  described  as  the  first 
stage. 

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SYMPTOMATOLOGY  129 

congested ;  the  eyes  often  brilliant ;  the  urine  high  coloured, 
but  no  albumin ;  the  face  and  upper  part  of  the  trunk  may  be 
flushed;  there  is  restlessness.  This  stage  is  in  fact  one  of 
stimulation,  the  virus  is  commencing  to  take  effect  on  the 
tissues  and  organs :  it  is  succeeded  by  the  second  stage  or  stage 
of  depression,  in  which  the  organs  show  that  their  metabolism 
is  now  profoundly  affected  by  the  virus,  the  symptoms  develop 
from  day  to  day. 

The  headache  and  pains  continue  and  increase ;  the  restless- 
ness becomes  more  marked  and  often  passes  into  delirium  of  a 
violent  character ;  the  gastric  symptoms  intensify  ;  the  vomiting 
is  more  severe ;  minute  specks  of  blood  begin  to  appear  in  it 
for  the  first  time ;  later  the  whole  vomit  becomes  dark,  like 
"  coffee  grounds,"  owing  to  the  escape  of  blood  into  it  derived 
from  the  intensely  congested  stomach  wall.  This  constitutes 
the  "  black  vomit "  :  it  is  essentially  a  sanguinolent,  serous  dis- 
charge from  the  congested  mucous  membrane,  comparable  to 
that  which  takes  place  from  the  nasal  cavity,  or  the  bronchioles, 
or  the  intestines,  when  the  mucous  membranes  of  these  tracts 
are  the  seat  of  intense  congestion. 

Flakes  of  lymph  are  found  in  the  vomit,  and  these  together 
with  the  mucous  and  red  corpuscles  constitute  the  coffee-ground 
deposit.  Sometimes  the  vomit  is  clearer  and  more  serous-like, 
sometimes  darker :  this,  we  can  readily  understand,  depends 
upon  the  degree  of  inflammation  of  the  mucous  membrane.  In 
some  cases  the  haemorrhagic  appearance  of  the  vomit  is  marked, 
just  as  in  haemorrhagic  pneumonia  :  in  this  case  the  vessels  bleed 
into  the  stomach. 

In  connection  with  the  mechanism  of  vomiting,  it  is  often 
noted  that  the  expulsion  of  the  contents  of  the  stomach 
takes  place  suddenly  without  any  effort.  I  have  myself  seen  this 
many  times.  The  vomit  wells  up  and  gushes  out  over  the  bed 
clothes  or  on  to  the  floor ;  hiccough  often  now  becomes  very 
troublesome  and  intractable. 

Sometimes  the  black  vomit  stage  is  not  reached,  and  it  is 

I 


130     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

only  at  the  post-mortem  examination  that  the  black  vomit  is 
found  in  the  stomach. 

Black  vomit  is  usually  compared  to  coffee  grounds ;  some- 
times it  is  described  as  bog  water  or  porter  like.  It  has  been 
mistaken  for  altered  red  wine,  and  the  unfortunate  patient  has 
been  picked  up  and  lodged  in  jail  as  drunken. 

The  congestion  of  the  mucous  membrane  of  the  stomach 
may  extend  to  the  gut,  and  dark  tarry  stools  may  take  the  place 
of  the  intensely  fetid  stool  of  the  first  stage.  No  doubt  some 
of  the  black  matter  present  in  the  stools  is  derived  from  the 
stomach. 

The  tendency  to  congestion  is  not  confined  to  the  alimentary 
tract ;  the  conjunctivae  and  skin  may  be  congested,  and  this  may 
markedly  increase  ;  petechias  or  small  subcutaneous  haemorrhages 
develop,  especially  in  dependent  and  injured  parts ;  the  gums, 
nose,  and  eyes  may  also  begin  to  bleed. 

The  effect  of  the  virus  begins  also  in  the  second  stage  to 
take  effect  on  the  vascular  system,  the  liver,  and  kidneys.  The 
temperature  is  rising  or  remaining  constant,  but  the  pulse  does 
not  quicken  to  correspond  with  it ;  on  the  contrary,  it  becomes 
slower.  This  characteristic  slowing  of  the  pulse  may  be  due  to 
the  markedly  altered  metabolism  in  the  liver,  whereby  the  bile 
salts  are  absorbed  and  lead  to  the  slowing  of  the  pulse. 

Jaundice  may  now  appear  in  the  scleras,  and  may  extend 
and  deepen  from  day  to  day  until  the  whole  surface  is  yellow, 
the  colour  of  the  urine  proceeds  pari  passu.  Sometimes,  as 
stated,  the  yellow  coloration  only  appears  during  the  death 
agony  or  just  after  death. 

The  progressive  character  of  the  lesions  is  also  observed  in 
connection  with  the  kidneys. 

The  urine  may  remain  free  from  albumin  for  the  first  three 
or  four  days,  and  then  the  albumin  may  begin  to  show  itself, 
at  first  as  a  trace,  gradually  increasing  in  amount ;  it  is  essential 
therefore  to  test  the  urine  frequently  throughout  the  day.  The 
quantity  of  urine  passed  may  begin  to  fall  off  and  be  suppressed 


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SYMPTOMATOLOGY  131 

for  one  or  more  days.  If  this  occurs,  the  mental  symptoms 
begin  to  gain  in  severity,  the  delirium  becomes  maniacal,  and 
is  usually  followed  by  coma  and  death. 

In  the  following  pages  I  have  grouped  together  the 
symptoms  which  have  been  observed  in  cases  of  yellow  fever 
which  have  occurred  in  Cuba,  Barbados,  British  Honduras,  New 
Orleans,  and  in  West  Africa.  Their  study  will  afford  an  exceed- 
ingly accurate  picture  of  the  disease. 

The  account  of  the  symptoms  of  the  cases  seen  in  West 
Africa  in  the  years  1823,  1837,  and  1847,  are  taken  directly 
from  the  reports  of  Staff-surgeons  Barry,  Fergusson,  and 
Lawson  respectively. 

These  reports,  which  for  neatness  and  powers  of  observation 
are  of  a  very  high  order,  are  preserved  in  the  medical  military 
reports  of  the  garrison  of  Freetown,  and  for  permission  to  see 
them  I  am  indebted  to  Colonel  Sutton,  R.A.M.C.,  and  the 
General  in  command.  This  is,  I  believe,  the  first  time  that  the 
reports  have  been  reproduced. 

References 
Faget  (J.  C.) — Fievre  jaane,  Paris,  1875. 
Fitzpatrick  (C.  B.) — "  Notes  upon  the  Experimental  Production  of  Faget's 

Diagnostic  Reaction  of  Yellow  Fever,"  New  York  Medical  Record, 

1 898- 1 899  ;  and   Collected  Studies,  Department  of  Health,   vol.   iv., 

p.  158,  New  York,  1909. 
La  ROCHE  (R.) —  Yellow  Fever,  Philadelphia. 

GOLDBERGER  (J.) — "Yellow  Fever,"  Bulletin  No.  16,  Washington,  1907. 
Blair  (Daniel) — Some  Account  of  the  Yellow  Fever  Epidemic  of  British 

Guiana,  London,  1850. 
GuiTERAS  (J.) — Sanidad y  Beneficiencia,  Cuba,  1909- 19 10. 
THOMAS   (H.  W.) — Annals  of  Tropical  Medicine  and  Parasitology,  1910, 

vol.  iv.,  No.  I. 

Symptomatology  of  Yellow  Fever  in  the   West  Indies  and 
Central  America 

Guiteras  has  recently  published  a  clinical  resume  of  275 
cases  of  yellow  fever,  as  well  as  the  findings  of  a  life's  experience 
in  yellow  fever  countries.     In  the  following  paragraphs  I  have 


132     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

embodied  the  observations  of  Guiteras,  and  have  added  the 
results  of  my  own  experience  in  Barbados  and  British 
Honduras. 

Guiteras  defines  yellow  fever  as  a  fever  of  from  two  to  seven 
days,  characterised  by  sudden  onset,  a  fastigium  of  from  one  to 
four  days,  followed  by  an  irregular  lysis,  sometimes  interrupted 
by  a  secondary  exacerbation. 

A  steady  fall  of  the  pulse,  commencing  in  the  fastigium  ; 
vomiting,  jaundice,  albuminuria  (tending  to  blood  stasis),  and 
finally  haemorrhages.  His  clinical  picture  of  the  disease  is  as 
follows : — 

"  During  the  early  hours  of  the  morning  the  patient  awakes 
with  a  slight  rigor,  and,  on  moving,  experiences  vertigo  and 
numbness,  and  heaviness  of  the  lower  extremities.  This  is 
followed  by  nausea,  and  in  some  instances  by  vomiting  of  the 
remains  of  the  last  meal ;  the  temperature  rises  rapidly ; 
frontal  headache,  rachialgia,  and  pains  in  the  limbs  develop, 
and  the  pulse  becomes  frequent.  The  face  assumes  an  injected, 
turgid  appearance ;  the  eyes  are  red  and  moist.  The  patient 
looks  like  a  person  who  had  indulged  in  an  alcoholic  debauch. 

"  During  the  day  the  fever  continues  to  rise,  and  the  patient 
complains  of  discomfort,  pain  or  burning  in  the  epigastrium, 
with  sensitiveness  to  pressure.  The  temperature  rises  between 
102°  and  1030  F.  and  the  pulse  to  100  or  no.  After  six  or 
nine  in  the  evening  of  the  first  day,  the  temperature  may  fall 
somewhat.     This  may  amount  to  a  distinct  remission. 

"  After  the  initial  elevation  of  the  temperature,  jaundice  will 
develop  sooner  or  later,  and  the  course  of  the  disease  may  vary 
according  to  three  different  types  :  the  desce?iding  or  mild  type, 
the  continued  type,  and  the  remitting,  complicated  or  secondary 
fever  type. 

"  The  vaso-motor  erethism  will  begin  to  subside,  together 
with  the  painful  symptoms,  after  the  diurnal  elevation  of 
temperature  of  the  second  day,  and  is  replaced  either  by  the 
evidences  of  a  gradual  return  to  the  normal,  or  by  the  signs  of 
blood  stasis  with  haemorrhages  from  the  mucous  membranes, 
or  with  the  syndrome  of  a  malignant  icterus. 

"  The  urine  becomes  albuminous  on  the  second  or  third  day 




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SYMPTOMATOLOGY  133 

of  the  disease.  The  mental  attitude  is  usually  one  of  alertness. 
Even  when  the  patient  is  delirious  the  expression  of  the  face  is 
apt  to  be  attentive,  though  the  mind  be  utterly  confused  and 
the  speech  wild.     In  some  cases  there  is  somnolence. 

"  The  pulse  begins  to  fall  on  the  second  day,  and  continues 
to  fall  even  though  the  temperature  may  rise.  Recovery  is 
usually  rapid,  and  sequelae  are  rare.  Independently  of  the 
course  of  the  temperature,  we  may  recognise  certain  types,  such 
as  the  uncomplicated,  the  haemorrhagic,  the  icteric,  the  ataxic, 
and,  as  rarer  forms,  the  anuric,  the  dystolic,  and  the  fulminating. 
The  various  combinations  of  these,  however,  are  of  too  frequent 
occurrence  to  give  these  types  any  practical  value." 

Guiteras  points  out  that  the  old  classical  description  of 
yellow  fever,  as  a  fever  of  two  paroxysms  separated  by  an 
interval  of  calm,  is  really  based  upon  clinical  observation,  and 
not  upon  the  use  of  the  thermometer. 

The  temperature  chart  is,  in  fact,  like  that  of  scarlet,  or  of  the 
other  specific  fevers.  In  other  words,  it  is  a  single  paroxysm 
fever ;  but  there  is  a  remitting  type,  which  shows  a  fall  of 
temperature  on  the  third,  fourth,  or  fifth  day.  In  this  case  the 
second  exacerbation  may  be  due  to  haemorrhages  or  to  second- 
ary infection. 

As  in  all  fevers,  however,  so  in  yellow  fever,  there  are 
oscillations,  and  there  is  nothing  absolutely  diagnostic  in  the 
chart. 

The  descending  type  is  mild,  and  corresponds  to,  no  doubt, 
the  acclimatising  or  endemic  fever  common  to  yellow  fever 
countries.  The  temperature  reaches  its  maximum  on  the 
evening  of  the  first  or  second  day,  and  then  falls  with  oscillations. 
It  is  a  mild  attack,  and,  no  doubt,  confers  a  certain  degree  of 
immunity.     Sometimes  these  cases  end  fatally. 

In  the  continued  type  the  high  temperature  is  protracted  ;  this 
form  is  usually  fatal,  and  the  delirium,  albuminuria,  and  suppres- 
sion of  severe  yellow  fever  may  be  present. 

Guiteras  regards  the  want  of  correlation  between  pulse  and 


134     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

temperature  as  one  of  the  most  constant  features  of  yellow 
fever.  He  points  out,  however,  that  a  sudden  fall  of  tempera- 
ture accompanied  by  a  rise  of  pulse  rate  is  obviously  a  very 
serious  symptom. 

Guiteras  also  emphasised  a  fact  which  is  brought  out  in  some 
of  the  clinical  histories  in  the  following  pages — namely,  the 
sense  of  false  security  which  an  apparently  good,  full,  and 
regular  pulse  of  70  will  induce  in  those  who  are  not  on  their 
guard. 

The  same  observer  lays  stress  upon  the  characteristic  facies 
of  yellow  fever,  the  ferrity  eyes,  and  the  constant  presence  of 
some  shade  of  yellow  in  the  skin  or  in  the  sclerae. 

"  The  dead  body  is  always  yellow  in  yellow  fever."  Vomit- 
ing is  by  no  means  a  constant  symptom,  persistent  vomiting  is 
a  grave  symptom :  the  first  signs  of  the  black  vomit  are  the 
appearances  of  the  "  fly  specks."  Black  vomit  may  be  absent  in 
severe  and  even  fatal  cases,  but  in  these  cases  the  black  fluid 
will  certainly  be  found  in  the  stomach  at  the  autopsy. 

Some  Cases  seen  in  Barbados,  1909 

CASE  I. — A.  L.,  black  native,  aet.  twenty-one. 

27th  February. — Felt  unwell. 

Ajh  March. — Admitted  into  hospital;  temperature  1010  ; 
pulse  100  ;  backache  ;  headache  ;  epigastric  tenderness  ;  vomit- 
ing ;  slight  icteric  tint ;  suppression  of  urine ;  a  small  quantity 
was  withdrawn  by  the  catheter :  it  contained  blood  and  much 
albumin.  Later  in  the  day  black  vomit  appeared  and  a  tarry 
stool  passed. 

$th  March. — Urine  withdrawn  by  catheter  :  it  contains  blood  ; 
great  restlessness  ;  temperature  1030 ;  pulse  104,  and  weak. 

yth  March. — Urine  passed  in  bed  ;  temperature  1050 ;  pulse 
96. 

8th  March. — Urine  containing  blood  withdrawn  by  catheter  ; 
temperature  falling;  pulse  rapid,  120;  death. 

This  case  shows  a  diminishing  pulse  with  rising  temperature  : 
there  was  a  temperature  of  1050  with  a  pulse  of  96.     This  was 


FlG.  15.  —  Temperature  and  pulse 
curves  in  the  "remitting  type." 
The  remission  occurs  in  this  case 
at  end  of  first  day.  Note  the  diver- 
gence of  the  pulse. — Guiteras. 


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Note  the  fall  of  the  temperature 
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termination. — Guiteras. 


[To  face  p.  134. 


SYMPTOMATOLOGY  135 

soon  followed  by  the  reverse  action,  the  temperature  fell  rapidly 
and  the  pulse  rate  quickened  :  these  were  very  serious  symptoms. 
In  addition  the  kidneys  were  severely  affected,  as  is  shown  by 
the  blood  and  albumin  and  the  suppression.  The  chart  is  very 
characteristic. 

Post-mortem  examination  made  by  me  three  hours  after  death 
showed  : — Subcutaneous  tissues  distinctly  stained  yellow  ;  liver 
congested  and  of  a  yellow  shade  of  colour ;  on  section  it 
presented  a  typical  boxwood  colour.  Kidneys  congested. 
Stomach  contents  consisted  of  dark  bloody  fluid  ;  the  mucous 
membrane  deeply  congested ;  pericardial  fluid  slightly  bile- 
stained  ;  substance  of  left  ventricle  soft.  Spleen  normal  in  size 
and  firm. 

The  above  case,  both  from  the  clinical  as  well  as  the  post- 
mortem findings,  is  a  typical  case  of  yellow  fever,  and  moreover 
of  yellow  fever  in  the  black  subject.  The  case  emphasises  the 
fact  that  the  black  is  not  necessarily  immune  to  yellow  fever. 

Case  II. — Mrs  G.,  a  native  resident. 

2jth  February. — Patient  taken  ill  with  chill,  followed  by 
headache ;  epigastric  pain  ;  nausea ;  examined  by  the  doctor 
who  found  temperature  102-5°  >  pulse  80;  albumin  present  in  the 
urine. 

3rd  March. — Chocolate-coloured  vomit ;  temperature  101-5°  5 
pulse  64 ;  much  nausea  and  epigastric  pain  ;  albuminuria. 

CASE  III.,  ■z'jth  February. — Taken  ill  with  rigor,  pain  in  the 
loins  ;  headache  ;  epigastric  tenderness  ;  no  vomiting.  Later 
the  sclerae  became  jaundiced  and  albumin  made  its  appearance 
in  the  urine ;  temperature  103-4° ;  pulse  88.  The  pulse  and 
temperature  rate  whilst  the  patient  was  under  observation  was 
as  follows : — 

Temperature  100-4°  \  pulse  80. 

Temperature  103° ;  pulse  80.     Temperature  102° ;  pulse  60. 

Some   Cases  observed  in  British  Honduras,   1905 

Case  I.— C.  R.  D.,  aet.  thirty-eight. 

\\th  May. — Taken  suddenly  ill  with  chill ;  temperature 
103-4°;  pulse  120;  headache.. 


136     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

16th  May. — Temperature  1030 ;  pulse  80 ;  tongue  furred, 
edges  red. 

iStk  May. — Temperature  1010,  then  rose  to  102-4°  5  pulse  72 
to  74.  Sclerae  yellow,  no  albuminuria.  Later  temperature  fell 
to  normal,  and  patient  recovered. 

CASE.  II. — J.  W.  C,  set.  thirty-two,  recent  arrival  in  Belize, 
but  many  years  on  East  African  coast. 

nth  February. — Woke  up  with  chill;  temperature  103-6.° 
pulse  72  ;  eyes  congested  and  sclerae  yellow  ;  urine  dark ;  trace 
of  albumin  ;  headache  ;  great  thirst. 

\2th  February. — Fair  night;  got  up;  sclerae  deeply 
jaundiced. 

i$th  February. — Feels  better,  but  headache  persists;  no 
albuminuria. 

i\th  February. — Patient  delirious;  temperature  102°;  urine 
diminished ;  much  albumin. 

\$tk  February. — Vomiting  of  food;  drowsy,  followed  later 
by  convulsions  and  death. 

CASE  III. — Miss  B.,  recent  arrival. 

^th  May. — Taken  ill ;  temperature  103° ;  pulse  120  ;  gastric 
irritability  ;  much  prostration  ;  no  headache  or  backache. 

Jth,  St/i,  gth  May. — Pulse  almost  normal,  and  patient  appeared 
to  have  recovered. 

lOtk  May. — Temperature  103°,  and  remained  almost 
stationary  till  death. 

14th  May. — Vomited  an  "  enormous "  quantity  of  brown 
fluid,  and  passed  a  large  quantity  of  same  fluid  material ;  the 
pulse  rate  rapid. 

In  this  case  the  "period  of  calm"  was  on  the  7th,  8th,  and 
9th,  and  no  doubt  the  almost  normal  pulse  put  the  medical 
attendant  off  his  guard. 

Case  IV.— Rev.  C. 

16th  May. — Taken  suddenly  ill  with  rigor;  temperature 
104°. 

igth  May. — Temperature  102°. 

20th    May. — Temperature     104° ;   pulse    48;    black   vomit 


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[To  face  p.  136. 


SYMPTOMATOLOGY  137 

albuminuria ;   petechias  on  palate ;   conjunctivae  congested  and 
yellow. 

27th  May. —  Death.  Post-mortem. — Stomach  contained  a 
large  quantity  of  black  vomit ;  liver  fatty,  said  to  have  presented 
a  typical  appearance. 

CASE  V. — F.  B.,  new  arrival. 

l%th  May. — Taken  ill  with  headache;  sleeplessness  and 
constipation;  temperature  ioic;  pulse  100. 

igtk  May. — Feels  better. 

2\st  May. — Temperature  103-4°;  pulse  76  ;  no  albumin. 

22nd  May. — Temperature  101-8°;  pulse  76  ;  albuminuria. 

2yd  May. — Temperature  100-2°;  pulse  74;  albuminuria. 

2/\th  May. — Temperature  dropped  to  subnormal ;  pulse  89. 

2^th  May. — Temperature  rose  to  102-4°  5  pulse  90  ;  delirium  ; 
death. 

CASE  VI. — Miss  N.  S.  E.,  aet.  twenty,  recent  arrival. 

22nd  May. — Taken  ill ;  feeling  bilious  ;  headache ;  face 
flushed ;  eyes  congested ;  tongue  furred ;  temperature  103  °; 
pulse  no.     Later  scleras  jaundiced  and  orescia. 

24^  May. — Vomiting  commenced. 

2$th  May. — Incessant  vomiting  of  dark  flocculent  matter. 

26th  May. — Vomiting  worse. 

27th  May. — Vomit  completely  black ;  urine  decreased ; 
albumin  present ;  delirium. 

2  8  #2  May. — Suppression  of  urine  ;  death. 

CASE  VII.— Major  B.,  aet.  forty-one. 

24^  May. — Taken  suddenly  ill  with  chill ;  temperature 
103-4° ;  pulse  102. 

2$th  May. — Remission  occurred  ;  temperature  99°. 

2%th  May. — Temperature  rose  to  103-4°;  pulse  100;  gastric 
haemorrhage  set  in. 

3 1  st  May. — That  is  the  eighth  day  of  illness  ;  black  vomit 
commenced ;  albumin  increased  in  quantity  in  the  urine, 
followed  by  suppression  and  death  on  4th  June  ;  that  is  the 
eleventh  day  of  illness, 


138     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

The  following  are  a  few  cases  described  by  Dr  Durham 
during  his  investigations  in  Para,  Brazil.  Dr  Durham  and  his 
companion,  Dr  Myers,  also  themselves  at  the  same  time  became 
infected,  Dr  Myers  fatally. 

Case  I. — Robust  middle-aged  woman  ;  arrived  from  France, 
1st  September  1900;  has  not  used  a  mosquito  net. 

ntk  September. — Quite  well  at  9  A.M.,  taken  with  some 
shivering  about  midnight ;  vomited  bilious  matter ;  severe 
headache. 

\2tJ1  September. — Severe,  intense  frontal  headache;  no  pain 
elsewhere ;  facies,  nil ;  chest,  nil ;  abdomen,  nil ;  tongue 
flabby;  skin,  moist,  sweating  slightly;  temperature,  38-7°; 
pulse,  118.  Four  P.M.  headache  still  severe;  pain  and  tender- 
ness at  epigastrium ;  pain  in  loins  and  calves ;  face  a  little 
flushed,  but  no  marked  facies  or  thoracic  injection ;  rather 
intense  photophobia ;  tongue,  furred ;  skin,  hardly  moist ; 
vomit,  yellowish,  with  a  good  deal  of  mucus ;  no  ague 
parasites  could  be  found  in  blood  films ;  temperature  37-6°  ; 
pulse  108.. 

13th  September. — Headache  less;  skin  moist;  no  icterus; 
no  conjunctival  injection ;  no  pain ;  no  vomit ;  complains  of 
weakness ;  temperature,  2>7°  '■>  pulse  84.  Evening,  temperature 
37° ;  pulse  98. 

\\t1i  September.  —  Some  headache ;  no  icterus ;  tongue 
slight  fur,  edges  red ;  papillae  swollen ;  tenderness  and  pain  at 
epigastric  angle ;  no  albumin  (boil  and  nitric) ;  temperature 
370  ;  pulse  98. 

15th  September. — No  icterus;  no  fever;  no  albumin;  gums 
rather  swollen.     Recovered. 

CASE  II. — Lives  in  a  chalet  which  is  very  full  of  mosquitos, 
partly  S.  fasciata,  chiefly  bred  in  the  ant  guards  of  the  pillars 
supporting  the  house,  and  partly  with  C.  fatigans,  probably 
from  the  stables.  Arrived  in  Para  from  France,  14th  July 
1900.     Sleeps  with  inefficient  mosquito  net. 

i$th  September. — Taken  suddenly  ill  in  evening;  at  8  P.M. 
temperature  40°. 


SYMPTOMATOLOGY  139 

\6tk  September. — Face  and  eyes  injected ;  skin  flushed  ; 
no  headache  or  pains ;  no  vomit ;  skin  dry  ;  tongue,  central  fur 
and  very  red  edges;  no  icterus;  no  albumin;  gums  not 
swollen;  slight  injection  of  fauces. 

iyth  September. — Still  flushed;  hardly  conscious;  some 
albuminuria  ;  no  icterus  ;  spleen  and  liver,  nil. 

iSt/i  September. — Still  flushed;  temperature  falling;  fair 
quantity  of  albumin  in  urine;  no  icterus. 

igt/i  September. — Feels  better;  no  icterus;  gums  not 
swollen. 

20th  September. — Some  epistaxis ;  gums  slightly  swollen  ; 
(?)  slight  conjunctival  icterus. 

2 1 st  September. — Some  epistaxis;  gums  much  swollen. 

22nd  September.  —  No  epistaxis ;  bleeding  now  from 
gums. 

2yd  September. — Distinct  conjunctival  icterus,  gums  bleed- 
ing;  albuminuria. 

26th  September. —  No  icterus  ;  feels  weak. 

2nd  October. — No  albumin  ;  appetite  returned. 

Case  III. — Middle-aged  man,  arrived  with  wife  from 
France. 

1st  October. — Taken  ill  in  the  afternoon  ;  temperature  390. 

2nd  October. — Complains  of  frontal  headache  and  lumbar  pain  ; 
temperature  normal ;  no  sweating  ;  examination  of  blood  for 
ague  parasites  negative ;  spleen  and  liver,  nil ;  eyes  rather 
injected. 

3rd  October. — Eyes  injected  ;  epigastric  pain  and  frontal 
headache  ;  tongue,  much  moist  white  fur ;  no  icterus ;  much 
bilious  vomiting;  no  albuminuria. 

4th  October. — Headache  persists ;  no  icterus ;  bilious 
vomiting ;  returns  all  ingesta ;  abdomen  not  tender ;  tongue, 
much  white  fur ;  acute  epigastric  pain  relieved  by  vomiting ; 
much  albumin  in  urine  ;  blood  examination  negative. 

$th  October. — Less  pain  ;  abdomen  rather  tender  ;  insomnia ; 
much  albumin  ;  no  vomiting ;  no  icterus. 

6th  October.  —  Pain  slight;  generally  better;  albumin 
moderate ;  no  icterus ;  weak  and  emaciated  ;  further  history, 
no  icterus  ;  no  haemorrhage  ;  gums,  nil. 


140     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

Staff-surgeon  Barry  on  the  Symptomatology  of  the  1823  Epidemic 
in  Freetown,  West  Africa 

"  In  the  1823  epidemic  in  Freetown,  the  attack  was  generally 
ushered  in  with  pain  in  the  loins,  limbs,  but  more  particularly 
in  the  calves  of  the  legs  ;  sometimes  distressing  pain  in  the  head, 
and  at  others  with  great  uneasiness  about  the  praecordia,  with 
occasional  vomiting  and  irritability  of  stomach,  the  tongue  in 
general,  white  and  tremulous,  in  some  cases  red  and  clean,  and 
in  a  few  an  ingrained  blackness  was  perceptible ;  but  perfectly 
different  from  that  collection  of  sordes  which  forms  a  char- 
acteristic of  the  typhus  gravior,  no  symptom  of  which  was 
apparent  during  any  stage  of  the  disease. 

"  There  was  no  great  degree  of  heat  of  the  surface  of  the  body, 
but  on  grasping  the  limbs  or  body  firmly,  a  very  peculiar 
sensation  of  stinging  heat  was  communicated  to  the  hand,  which 
is  retained  for  a  considerable  time.  The  pulse  hurried  and 
sometimes  full,  but  seldom  indicating  any  considerable  degree  of 
inflammatory  action.  No  remarkable  appearance  of  the  urine  ; 
the  eyes  were  generally  suffused,  and  in  most  cases  there  was 
considerable  anxiety  during  the  first  stage  of  the  disease. 

"  This  train  of  symptoms  generally  lasted  for  the  first  thirty- 
eight  or  forty  hours,  by  which  time  the  aperient  medicines  which 
had  been  administered  had  freely  operated,  but  in  vain  were 
healthy  bilious  evacuations  sought  for,  the  disease  now  became 
evidently  manifest  in  the  thin  dark  fluid  which  was  passed 
downwards  in  considerable  quantities  and  rendered  particularly 
characteristic  by  innumerable  small  floating  flocculi  which  had 
very  much  the  appearance  of  the  washed  and  broken  down 
fibrin  of  the  blood. 

"  The  patient  about  this  period  felt  much  relieved,  and 
appeared  unconscious  of  his  danger,  and  this  delusive  state  often 
gave  sanguine  hopes  to  the  attendants.  This  calm  was  followed 
by  a  morbid  torpidity,  or  sometimes  by  low  delirium  ;  this  state 
continued  until  the  fourth  day,  when  the  inevitable  forerunner  of 
a  fatal  termination,  the  "  Black  Vomit,"  made  its  appearance,  at 
first  in  small  quantities  and  mixed  with  the  ingesta,  but  after- 
wards in  amazing  volumes,  and  ejected  from  the  stomach  with  a 
most  extraordinary  spasmodic  force. 


SYMPTOMATOLOGY  141 

"  The  fluid  has  the  appearance  of  broken  down  and  diluted 
coagulum  of  the  blood,  and  frequently  with  portions  of  coagu- 
lated lymph  assuming  very  much  the  appearance  of  the  inner 
coat  of  the  stomach.  The  fluid  gave  a  dark  stain  to  the  linen 
not  easily  removed,  and  had  a  raw,  unpleasant  odour,  so 
perfectly  peculiar  that  on  entering  the  chamber  the  state  of 
affairs  become  immediately  manifest.  In  some  cases  a  trouble- 
some hiccough  occurred,  and  in  those  the  matter  vomited  was 
less  abundant. 

"  The  state  of  the  patient's  mind  was  most  peculiar  in  this 
latter  stage,  and  generally  expressed  himself  as  being  much 
better,  until,  the  vital  flame  gradually  receding  from  the 
surface  and  extremities,  dissolution  took  place,  which  in  some 
cases  was  preceded  by  violent  straining  of  the  eyeballs, 
incoherent  expressions,  or  by  some  convulsive  motions ;  some- 
times prior  to  this  a  dingy  yellow  appearance  took  place  on  the 
body,  particularly  on  the  neck  and  chest." 

Staff- surgeon  Fergus  son  on  the  Symptomatology  of  the  1837 
Yellow  Fever  Epidemic,  Freetown,  West  Africa 

"  Premonitory  symptoms  did  not  always  occur,  but  when 
they  did  occur  they  were  of  short  duration.  The  person  about  to 
be  attacked  having  been  in  the  enjoyment  of  ordinary  good 
health,  awoke  some  morning  with  a  sensation  as  if  all  was  not 
right  with  him.  He  was  not  absolutely  sick,  nor  in  fever,  but  had 
a  sort  of  confused  recollection  that  he  had  not  passed  a  comfort- 
able night — perhaps  had  dreamed  more  than  usual — he  felt 
languid,  and  yawned  occasionally ;  tongue  furred  but  not 
thickly  so. 

"  This  state  was  soon  followed  by  a  sense  of  dryness  of  skin, 
headache,  pains  in  the  back  and  loins,  sometimes  extending  to 
the  thighs,  knees,  and  legs  ;  he  became  alternately  cold  and  hot ; 
sometimes  there  was  a  rigor  ;  at  this  early  stage  the  eyes  became 
suffused,  and  an  increased  number  of  small  red  points  were 
developed  on  the  conjunctivae  ;  the  pulse  rose  rapidly  to  96,  100, 
or  120;  the  temperature  of  the  surface  became  rapidly  and 
permanently  increased ;  this  stage  was  also  in  some  cases 
accompanied  by  a  sense  of  nausea,  in  others  by  copious 
vomiting  of  tea,  lemonade,  toast,  water,  or  other  ingesta,  which 


142     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

an  unusual  degree  of  thirst  had  induced  the  patient  to  swallow; 
the  tongue  now  became  more  densely  furred,  and  all  the 
symptoms  increased  in  intensity  until  what  was  mere  malaise  in 
the  morning  had  by  mid-day  merged  into  an  unequivocal 
paroxysm  of  fever ;  towards  evening  the  symptoms  became 
more  aggravated,  skin  dry,  parched,  and  hot ;  the  carotids 
throbbed  violently,  the  headache  was  also  more  severe,  but  this 
symptom,  though  severe,  was  usually  pretty  tolerable  so  long  as 
the  patient  kept  in  the  horizontal  posture ;  but  when  he 
attempted  to  get  up,  the  forcible  closing  of  the  eyes  and  the 
general  appearance  of  the  countenance  bore  sufficient  evidence 
of  the  agony  that  was  endured  ;  pressure  with  the  finger  on  the 
eyeball  caused  great  pain ;  moving  the  eye  upwards  and  out- 
wards also  caused  pain  in  the  eyeball.  Besides  these  symptoms 
there  was  a  sense  of  general  distress  wholly  distinct  from  pain, 
which  it  is  not  easy  to  describe.  There  was  seldom  any  tender- 
ness or  pain  on  pressure  of  the  epigastrium  or  hypochondrium, 
and  even  when  that  symptom  did  exist,  it  was  in  a  very  trivial 
degree.  The  first  night  was  always  one  of  great  suffering.  As 
the  night  advanced  the  headache  became  excessive,  and  all  the 
symptoms  still  more  aggravated.  In  some  cases  the  patient  slept ; 
in  others  he  was  utterly  sleepless  and  restless,  tossing  about  in 
the  vain  search  for  a  cool  place  to  lay  his  head  on.  But  whether 
he  slept  or  not,  still  the  night  was  one  of  great  suffering.  Such 
sleep  as  that  by  which  the  patient  was  visited  was  anything  but 
repose,  for  no  sooner  were  the  eyes  closed  than  a  thousand 
incongruous  fancies  flitted  before  the  imagination.  The  patient 
in  this  stage  is  quite  conscious  that  his  fancies  are  delusive  and 
incongruous,  but  no  effort  of  reason  can  divest  his  mind  of  the 
certainty  of  their  actual  presence,  and  the  constant  and  unavail- 
ing effort  to  rectify  his  perceptions  is  productive  of  the  utmost 
distress.  There  is  a  consciousness  of  the  incongruity  of  ideas, 
and  a  desire  to  exert  the  rational  faculties,  though  these  are  not 
subservient  to  the  will.  One  grade  beyond  this  in  the  severity  of 
the  disease,  and  this  last  ray  of  consciousness  is  lost  in  delirium. 
"  Towards  morning,  or  about  5  or  6  A.M.,  the  patient  generally 
falls  into  a  deep  sleep,  sound  and  without  dreaming.  This  may 
continue  from  one  to  three  hours,  and  when  he  awakes,  the 
whole  surface  is  covered  with  a  gentle  moisture ;  the  headache, 


SYMPTOMATOLOGY  143 

pain  of  limbs,  and  general  distress  are  all  alleviated  ;  the  pulse 
has  subsided  to  78  or  76 ;  the  tongue,  however,  retains  its  coat- 
ing, and  the  eyes  are  probably  more  suffused. 

"  During  the  first  twenty-four  hours  a  large  quantity  of 
semifluid  fsecal  matter  of  a  dark  green  colour  is  evacuated  ; 
succeeding  evacuations  become  less  faecal  and  more  watery 
until  at  length  the  dejections  consist  solely  of  a  dark  watery 
fetid  substance,  interspersed  with  whitish  fioculi ;  about  this 
time  the  patient's  countenance  assumed  a  darker  hue  than 
usual,  and  the  conjunctiva  betrays  a  slight  tinge  of  yellow.  He,  is, 
however,  on  the  whole,  much  better,  and  is  more  comfortable  in 
all  his  feelings  :  he  has  not  the  slightest  appetite  nor  desire  for 
food,  the  thirst  is  moderate,  and,  in  fact,  he  would  be  altogether 
well  were  it  not  for  a  very  uncomfortable  feeling  of  giddiness  in 
his  head  when  he  attempts  to  rise.  In  some  cases  there  is  a 
second  febrile  paroxysm  similar  to  the  one  described ;  in  other 
cases  there  is  even  a  third,  but  very  commonly  there  is  no 
decided  second  paroxysm.  This  is  more  especially  apt  to  be  the 
case  in  those  instances  where  the  disease  terminates  fatally  at 
an  early  period. 

"  The  second  stage  of  the  disease  is  of  a  most  delusive  nature  : 
the  skin  is  cool,  in  many  cases  it  is  moist ;  the  pulse  is  commonly 
enlarged  in  volume,  and  from  68  to  76,  rarely  exceeding  the 
latter ;  the  thirst  is  moderate  ;  the  tongue  in  many  cases  moist, 
and  not  much  loaded,  with  a  scarcely  perceptible  redness  around 
the  edges  and  at  the  tip,;  it  is  in  many  cases  remarkably  tremulous 
when  protruded  ;  in  fact  a  stranger  to  the  insiduous  nature  of 
the  disease  would  at  once  pronounce  the  patient  in  this  state  to 
be  a  safe  case,  and  at  the  point  of  convalescence.  Although 
there  is  little  suffering  and  little  complaint,  yet  when  the  patient 
endeavours  to  rise,  his  gait  is  unsteady,  he  staggers  towards  the 
closet  stool  as  if  he  were  intoxicated  ;  the  dejections  continue 
dark,  watery,  fetid,  and  fiocculent ;  the  eyes  are  much  suffused, 
and  the  colour  of  the  countenance  now  deepens  into  the 
swarthy  appearance  of  a  dark  Spaniard  or  Italian,  or  of  a  person 
deeply  sunburnt.  If  there  has  been  no  second  paroxysm  the 
patient  is  now  pretty  comfortable  during  the  day.  His  nights 
are,  however,  very  distressing  :  he  is  restless  or  sleepless  as  before, 
or  his  sleep  is  again  disturbed  by  incongruous,  visionary  fancies, 


144    CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

till,  towards  morning  on  the  second  or  third  day,  a  distressing 
irritability  of  stomach  sets  in.  The  pulse  is  not  usually,  however, 
affected  by  it  either  in  strength,  or  volume,  or  frequency.  The 
substance  thrown  off  consists  at  first  merely  of  the  ingesta, 
mixed  with  a  little  froth  or  perhaps  green  or  yellow  bile. 
Careful  and  minute  inspection  will  frequently  at  an  early  period 
detect  among  the  substance  vomited  the  incipient  state  of  that 
which  afterwards  forms  the  "  black  vomit."  It  is  difficult  to 
describe  this  appearance  in  its  early  stage  so  as  to  make  it 
intelligible,  but  a  near  approach  to  it  may  be  seen  in  the  boiled 
coagula  which  float  in  soup  made  of  meat  from  which  the  blood 
had  not  been  well  washed,  minute  shreds  of  a  similar  looking 
substance  from  the  incipient  stage  of  "  black  vomit."  The 
patient  may  continue  in  the  state  here  described  for  one,  two, 
three,  or  more  days,  the  irritability  of  stomach  and  vomiting 
continuing  with  more  or  less  severity  until  the  full  development 
of  the  "black  vomit"  throws  a  shade  over  the  countenance  of 
both  patient  and  medical  attendant.  The  patient  now  sinks 
gradually.     Sometimes  petechiae  appear. 

"  The  tongue  may  be  dry,  hard,  horny,  the  papillae  communi- 
cating, when  touched  by  the  finger,  a  sensation  as  if  the  finger 
grated  on  sandpaper  ;  at  other  times  it  is  clean  and  smooth, 
divested  of  even  the  smallest  appearance  of  papillae;  again  it  is 
black  and  dry ;  again  it  is  red  like  a  piece  of  raw  beef,  enlarged 
in  volume  or  shrivelled  in  size.  Large  quantities  of  coffee-ground- 
looking  substance  are  thrown  off  the  stomach ;  there  is  great 
anxiety  of  countenance  ;  the  breathing  becomes  oppressed  and 
laborious ;  the  whole  surface  is  covered  with  cold,  clammy 
perspiration ;  the  pulse  ceases  at  the  wrist.  The  patient  at  this 
stage  has  usually  been  for  some  hours  comatose,  before  the  scene 
is  closed  in  death. 

"  The  above  is  merely  an  outline  of  the  prominent  and  more 
common  features  of  the  disease,  but  innumerable  varieties  of 
detail  are  met  with,  not  only  in  individual  cases  but  also  in  the 
general  character  of  the  epidemic  at  different  times  of  its 
appearance.  Thus  in  1829,  the  invasion  of  the  disease  was 
ushered  in  by  greater  severity  of  pain  in  the  back,  loins,  thighs, 
knees,  and  legs  than  what  accompanied  its  early  stages  either 
in  the  early  part  or  towards  the  close  of  1837. 


SYMPTOMATOLOGY  145 

"  In  one  case  there  was  most  painful  and  protracted  cramps  of 
the  calves  of  the  legs,  during  which  the  gastrocnemii  muscles 
were  drawn  up  hard  and  round  like  a  ball.  In  another  case 
death  was  preceded  by  most  painful  spasms  of  the  hands  and 
arms.     Nothing  of  the  sort  appeared  in  1837. 

"  In  the  second  visitation  of  1837  there  was  for  some  time  in 
nearly  every  case  an  exudation  of  blood,  even  in  the  early  part 
of  the  disease,  from  the  mouth,  nose,  and  arms.  The  appearance 
of  petechiae  also  set  in  earlier  and  was  much  more  common  ; 
whereas  in  the  visitation  of  1829  and  in  the  primary  one  of  1837, 
I  did  not  meet  with  a  single  case  accompanied  by  sanguineous 
exudation. 

"  In  the  latter  part  of  1837,  there  occurred  several  cases  in 
which  the  patient  was  immersed  in  perspiration  and  covered 
with  petechiae  from  the  very  commencement  of  the  disease.  In 
these  cases  the  blood  exuded  from  the  mouth,  but  flowed  from 
the  nose  in  a  stream,  and  that  sometimes  to  an  alarming  extent. 
In  many  cases  the  urinary  secretion  was  more  or  less 
suppressed.  In  some  a  period  of  three  days  and  nights  elapsed 
without  a  drop  of  urine  having  been  voided  ;  this  state  was  not 
accompanied  by  any  symptoms  of  retention. 

"  In  many  cases  the  nervous  system  was  affected  in  an 
extraordinary  degree  :  the  staggering  gait  of  the  patient  on  an 
attempt  to  rise  has  been  noticed,  as  also  the  remarkable 
tremulousness  of  the  tongue  when  that  member  was  protruded  ; 
a  similar  tremulous  affection  of  the  hands  and  arms  was  not 
uncommon.  In  several  cases  not  only  the  conjunctiva,  but  the 
face  and  trunk  also  were  deeply  jaundiced  ;  but  in  the  generality 
of  cases  the  colour  did  not  deepen  beyond  the  dark,  swarthy 
appearance  above  noted. 

"To  enumerate  all  the  varieties  that  have  been  met  with 
would  be  an  endless  task.  I  shall  therefore  sum  up  this  part  of 
these  observations  with  a  statement  of  the  symptoms  which  I 
consider  as  being  pathognomonic  of  the  disease,  not  that  they 
are  by  any  means  of  uniform  or  constant  occurrence  in  every 
case,  but  because  they  have  been  less  frequently  absent  than 
any  of  the  others,  viz. : — 

"(1)  The     slow     and    languid    pulse     which    succeeds    the 
cessation  of  the  first  or  second  pyrexial  paroxysm. 

K 


146     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

"(2)  The   delusive  absence  of  obvious  pyrexial  symptoms 

which  accompanies  this  state. 
"  (3)  Concomitant  with  these  the  suffusion  of  eyes. 
"  (4)  The  '  black  vomit.' 

"  The  pathological  appearance  observed  on  dissection  were 
few  in  number,  but  these  were  of  such  constancy  and  uniformity 
as  might,  apj'iori,hQ  considered  almost  incompatible  with  the  great 
variety  in  the  symptoms  during  life  as  exhibited  in  individual 
cases.  The  head  was  rarely  examined  as,  in  those  cases  in  which 
it  was  examined,  nothing  pathologically  referrable  to  the  disease 
could  be  detected.  The  leading  feature  in  the  post-mortem 
inspection  was  an  obvious  and  unequivocal  appearance  of 
inflammatory  action  over  the  external  as  well  as  the  internal 
surface  of  the  stomach  and  intestinal  canals.  This  was 
repeatedly  noticed  in  every  grade,  from  a  minute  arborescence 
of  small  vessels  to  a  dark  livid  state,  in  which  the  coats  of 
intestine  were  easily  lacerable  ;  in  short  to  a  state  bordering  on 
sphacelus.  I  met  with  but  one  exception  to  this  condition  of 
increased  vascularity.  The  livid  appearance  when  present  was 
never  observed  on  the  stomach,  rarely  on  the  large  intestine, 
and  was  most  frequently  found  on  portions  of  ileum.  The  coats 
of  the  intestine  at  these  parts  were  very  much  thickened ;  the 
omentum  was  extremely  vascular.  The  stomach  in  all  cases 
was  found  to  contain  more  or  less  of  the  dark,  grumous 
substance  called  'black  vomit'  This  substance  adhered 
tenaciously  to  the  hands,  and  was  not  easily  washed  off.  After 
having  submitted  the  inner  coats  of  the  stomach  to  repeated 
washings,  a  thick  glairy  mucus  was  found  adherent  to  it,  through 
which  red  patches  were  observed,  varying  greatly  in  size  and 
shape,  but  generally  more  abundant  towards  the  pyloric  than 
the  cardiac  orifice.  When  the  mucus  was  scraped  off  and  those 
patches  viewed  through  a  magnifier,  they  appeared  to  consist  of 
a  congeries  of  minute  red  points.  They  displayed  no  appearance 
of  arborescence,  or  of  continuity  of  canal,  and  I  could  not  help 
regarding  them  as  so  many  minute  orifices  from  which  the 
blood  in  a  state  of  fluidity  was  exuded,  which  afterwards 
constituted  the  substance  called  '  black  vomit'  The  contents  of 
the  intestinal  canal  throughout  were  of  a  dark  colour,  and  the 
coats,  both  externally  and  internally,  bore  marks  of  vascularity 


SYMPTOMATOLOGY  147 

less  equivocally  indicative  of  precedent  inflammatory  action 
than  the  congeries  of  minute  points  of  which  the  red  patches  in 
the  stomach  were  formed.  The  liver  was  commonly  of  a  pale 
colour,  sometimes  mottled.  The  gall-bladder  not  so  frequently 
distended  as  in  the  ordinary  remittent  fever ;  its  contents  dark, 
viscid,  and  tar-like.  The  spleen  rarely  altered  either  in  size  or 
structure,  and  that  never  to  a  great  extent.  In  one  case  there 
was  a  large  flat  sanguineous  clot  found  under  the  dura  mater, 
and  in  the  same  case  a  similar  clot  was  found  within  the  sheath 
of  the  rectus  abdominis  muscle." 

Staff-surgeon  Lawson  on  the  Symptomatology  of  the  1847 
Yellow  Fever  Outbreak. 

"John  Ogden,  marine,  of  H.M.S.  Growler,  was  attacked  with 
remittent  fever  on  15th  March  1847,  and  on  examination 
was  found  to  be  labouring  under  the  following  symptoms  on 
the  1 6th  : — Considerable  frontal  headache,  flushed  countenance, 
skin  hot  and  dry  ;  tongue  covered  with  a  yellow  fur  in  the  centre, 
being  slightly  red  and  dry  in  the  tip  and  edges ;  constant 
nausea,  occasionally  vomiting  a  bilious-looking  fluid,  accom- 
panied by  epigastric  tenderness.  Pulse  quick  and  full ;  urine 
scanty  and  turbid,  depositing  a  sediment  on  cooling.  Bowels 
confined ;  occasional  attacks  of  shivering,  accompanied  by  pain 
along  the  spine.  A  sample  of  calomel  was  administered 
immediately,  followed  in  three  hours  afterwards  by  a  solution 
of  sulphate  of  magnesia  in  peppermint  water.  A  sinapism  was 
applied  to  the  epigastrium,  and  the  body  sponged  with  lime 
juice  and  water. 

"  In  the  evening  a  remission  took  place,  and  he  felt  himself 
much  better  in  every  respect ;  the  bowels  having  been  freely 
acted  on  by  the  medicines,  producing  several  stools,  the  evacua- 
tions being  fetid  and  of  a  dark  brown  colour. 

"  iSth  March. — Three  days  after  the  accession  of  the  disease 
the  symptoms  daily  decreased  in  severity  from  this  period,  and 
on  the  morning  of  the  21st  he  stated  that  he  had  slept  well 
during  the  night,  that  he  felt  quite  well,  and  wished  for  some- 
thing to  eat.  He  was  allowed  2  oz.  of  arrowroot  for  dinner, 
which  he  enjoyed  very  much,  and  at  the  evening  visit  was  quite 
free  from  any  febrile  symptom.     About  1 1    o'clock   the   same 


148     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

night  he  suddenly  screamed  in  his  sleep,  started  out  of  bed,  and 
attempted  to  jump  out  of  the  window.  On  visiting  him 
immediately,  I  found  him  labouring  under  great  mental 
excitement — his  face  flushed,  his  eyes  brilliant,  skin  dry  and 
burning,  with  slight  tremor  of  the  hands.  Pulse  rapid,  but  soft 
and  easily  compressed.  He  spoke  incoherently,  and  had  to  be 
restrained  in  bed.  He  vomited  a  considerable  quantity  of  a  dark 
coloured  fluid,  resembling  coffee  grounds.  Notwithstanding  the 
active  remedial  measures  employed,  symptoms  of  coma  came  on 
in  a  few  hours  afterwards,  and  he  died  at  9  o'clock  on  the 
following  night — the  22nd." 

Post-mortem  Appearances 

Cranium. — "  The  sinuses  and  central  veins  slightly  congested 
membranes  of  brain  perfectly  healthy.     There  was  about  two 
teaspoonfuls  of  serum  in  the  lateral  ventricles." 

Thorax. — "  Lungs  and  heart  healthy." 

Abdomen. — "  Stomach  was  found  half  filled  with  a  dark 
coloured  fluid,  similar  in  appearance  to  that  vomited,  having 
some  resemblance  to  the  '  black  vomit ' ;  but  on  minutely 
examining  it,  it  was  found  to  consist  of  shreds  of  lyinph,  mixed 
with  the  secretion  of  the  stomach  and  the  medicines  adminis- 
tered. The  membrane  covering  the  cardiac  extremity  was  soft 
and  easily  separated  from  the  cellular  coat,  and  presented 
vascular  patches  throughout.  The  remainder  of  the  abdominal 
viscera  were  perfectly  healthy." 

Comment. — The  above  case  is  of  interest,  because  it  shows  tin 
the  first  place  that  it  was  diagnosed  as  remittent  fever,  although 
there  can  now  be  no  doubt  that  it  was  yellow  fever.  In  the 
second  place,  it  is  clinically  of  interest  because  of  the  relapse  or 
"  feeling  better  stage."  In  this  stage  the  fatal  error  of  giving  food 
was  made  ;  this  invariably  precipitates  an  attack  of  black  vomit. 

The  History  of  the  1884  Yellow  Fever  Epidemic  in  Freetown, 
West  Africa 

The  following  report  of  the  1884  epidemic  of  yellow  fever  in 
Freetown  is  very  valuable  from  many  points  of  view.  The 
epidemic  to   commence  with   affects  both  the  blacks   and   the 


SYMPTOMATOLOGY  149 

whites,  but  the  severe  cases  which  develop  are  amongst  the 
whites.  There  is  not  one  fatal  case  amongst  the  black  population, 
with  the  exception  of  a  black  West  Indian  soldier. 

In  my  opinion  this  is  conclusive  evidence  that  the  black 
population  of  Freetown  had  been  protected  by  previous  attacks 
of  the  disease,  the  Europeans,  especially  the  newcomers,  were 
not  so  protected,  and  naturally  developed  the  severe  and  fatal 
type  of  yellow  fever. 

The  West  Indian  soldier  likewise  was  no  doubt  a  non- 
immune, just  as  in  1909  in  Barbados  I  found  that  the  mortality 
was  very  high  amongst  the  native  black  population,  for  they  had 
been  protected  from  the  disease  for  many  years,  and  naturally 
became  non-immune.  It  is  also  most  noteworthy  that  the 
Medical  Board  concluded  that  the  epidemic  was  of  local 
origin. 

Thirdly,  the  Board,  like  many  others,  experienced  the 
difficulty  of  distinguishing  the  endemial  local  remittent  fever 
from  yellow  fever.  They  mention  two  cases  of  remittent  fever 
which  ended  in  black  vomit.  In  other  words,  they  did  not 
realise  that  in  the  cases  of  remittent  fever  they  very  often  had 
yellow  fever  in  its  less  severe  types. 

Report  by  Sir  Arthur  Havelock  and  of  his  Medical  Board  to  the 
then  Secretary  of  State  for  the  Colonies,  Earl  Derby,  upon 
the  1884  Epidemic  of  Yellow  Fever  in  Freetown 

This  report  is  most  interesting,  because  it  shows  that  the 
observers  could  not  differentiate  between  bilious  remittent 
fever  and  yellow  fever. 

"  During  the  month  of  May  last  and  the  early  part  of  June,  a 
form  of  fever  which  was  described  by  the  acting  colonial  surgeon 
as  typho-malarial  fever  became  prevalent.  Europeans,  and 
especially  the  Europeans  who  had  recently  arrived  at  Sierra 
Leone,  appeared  to  be  more  subject  than  others  to  the  attacks 
of  this  disease.  It  proved  fatal  in  many  cases.  The  malignant 
symptoms  of  this  fever  became  more  marked  from  day  to  day. 


150     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

"  On  the  27th  of  June,  the  acting  colonial  surgeon  described 
it  as  a  pernicious  remittent  fever  on  the  borderland  of  yellow  fever. 
At  the  same  time,  one  of  the  private  practitioners  in  Freetown 
expressed  his  opinion  that  the  fever  in  question  had  already 
assumed  the  form  of  yellow  fever  of  a  mild  type  ;  and  the  senior 
military  medical  officer  reported  the  death  from  yellow  fever  of 
a  soldier  of  the  Second  West  India  Regiment.  On  28th 
June,  a  European  died  of  a  disease  described  by  the  acting 
colonial  surgeon  as  'black  vomit.'  On  2nd  July,  two  deaths 
of  Europeans  were  attributed  by  the  same  officer  to  yellow  fever. 
On  6th  July,  another  European  died  of  yellow  fever. 

"  The  disease  seems  then  to  have  begun  to  assume  a  less 
virulent  type.  Several  cases  of  yellow  fever  were  reported,  but 
recovery  was  made  in  all  instances  except  one,  which  ended 
fatally  on  the  16th  instant.  On  12th  July  the  acting 
colonial  surgeon  informed  me  that  all  cases  of  fever  seemed  to 
be  becoming  amenable  to  treatment. 

"The  final  opinion  with  regard  to  the  nature  of  the  disease, 
which  was  given  on  the  17th  instant  by  the  acting  colonial 
surgeon  on  his  own  behalf,  and  on  that  of  the  other  practitioners 
in  Freetown  was,  that  it  was  a  mild  type  of  yellow  fever  of  a  non- 
contagious nature. 

"  A  remarkable  feature  in  the  course  of  the  progress  of  this 
disease  is  that,  as  it  assumed  a  more  virulent  form  its  prevalence 
became  more  and  more  restricted  to  persons  of  European  birth, 
till  at  the  point  at  which  it  reached  its  worst  stage  and  was 
admitted  to  be  yellow  fever,  the  natives  seemed  to  have  complete 
immunity  from  its  attacks. 

"With  the  exception  of  the  case  of  a  soldier  of  the  regiment 
in  the  garrison  here,  a  West  Indian  negro,  the  cause  of  whose 
death  is,  as  I  have  already  mentioned,  stated  to  have  been 
yellow  fever,  there  has  not  been  a  single  authenticated  case  of 
that  disease  among  the  negro  population. 

"A  considerable  number  of  cases  of  serious  illness,  resulting 
in  death  in  the  case  of  four  Europeans,  having  occurred  during 
the  latter  part  of  May  and  the  first  fortnight  of  June,  within  a 
narrow  area  in  the  central  and  best  quarter  of  Freetown,  I 
appointed  a  Medical  Board,  composed  of  the  acting  colonial 
surgeon,  the   senior   military  medical   officer,  and  Dr    Cole,  a 


SYMPTOMATOLOGY  15 1 

private  practitioner,  to  inquire  into  the  causes  of  the  special 
unhealthiness  of  the  quarter  in  question,  and  of  the  general 
prevalence  of  fever  of  a  dangerous  type.  I  enclose  a  copy  of 
the  report." 

Medical  Report 

The  proceedings  of  a  Medical  Board  ordered  by  His 
Excellency  Sir  Arthur  Havelock,  K.C.M.G.,  to  assemble  for  the 
purpose  of  Investigating  and  Reporting  upon  the  causes  which 
have  originated  the  malignant  fever  now  so  fatal  in  Freetown, 
particularly  that  part  of  it  known  as  Westmorland  Street, 
Ravvdon  Street,  and  Howe  Street,  and  other  localities.  The 
Board  having  assembled  beg  to  lay  the  following  report  before 
His  Excellency  the  Governor-in-Chief  for  the  information  of 
the  Secretary  of  State  for  the  Colonies. 

Definition. — "  The  character  of  the  fever  which  has  caused 
such  extensive  sickness  and  mortality  amongst  the  natives  and 
Europeans  living  in  Freetown,  and  more  especially  in  that 
limited  area  known  as  Westmorland,  Rawdon,  and  Howe 
streets,  resembles  yellow  fever  or  that  form  of  pernicious 
remittent  fever  of  a  malignant  destructive  type  having  as  its 
characteristics  yellowness  of  the  skin  and  conjunctivae  with  dark 
coloured  and  very  offensive  alvine  evacuations — dark  coloured 
urine  containing  blood  casts  and  obvious  albumin — a  quick 
pulse  and  a  persistently  high  temperature  ranging  from  102°  to 
1050  F.  Vomiting  often  persistent  and  very  difficult  to  control, 
dark  in  colour,  and  containing  a  large  quantity  of  bile  in  some 
cases  with  distinctly  black  vomit.  Duration  of  this  form  of 
pernicious  remittent  fever  may  be  said  to  be  from  five  to  seven 
days,  but  in  malignant  cases  four  or  five  days. 

"  On  every  occasion  that  typho-malaria,  enteric,  or  per- 
nicious remittent,  or  yellow  fever  has  appeared  in  Freetown 
epidemically,  it  has  nearly  always  been  of  sporadic  origin,  the 
undoubted  product  of  Freetown  itself,  as  all  attempts  to  trace  it 
to  a  non-sporadic  origin  have  totally  failed,  except  when 
brought  here  by  a  sailing-vessel  once  from  Rio  Janeiro  in 
1872. 

"  The  prevalence  of  this  severe  form  of  typho-malarial  fever 
or  yellow  fever  now  so  fatal  among  the  European  and  native 
residents,  and  many  still  ill  with  fever  in  the  town,  undrained 


152    CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

insanitary  areas  of  the  town  may  be  a  warning  of  the  approach  of 
its  more  deadly  sister — malignant,  remittent,  paludal,  or  yellow 
fever." 

History. — "  There  may  be  stated  to  be  four  forms  of  febrile 
disease  usually  met  with  on  the  west  coast  of  Africa,  viz., 
intermittent  fever  or  ague,  remittent  fever,  enteric  or  typho- 
malarial  fever,  and  pernicious  malignant  or  yellow  fever. 

"  Although  the  characters  of  these  fevers  when  fully  developed 
have  been  freely  and  frequently  described,  and  show  a  distinct- 
ness of  type  one  from  the  other,  yet  so  numerous  are  the  con- 
necting links  which  bind  them  together  that  much  experience 
and  careful  investigation  is  required  before  absolutely  and 
positively  declaring  the  type  to  be  of  the  yellow  fever  character 
or  that  modified  form  of  it,  viz.,  typho-malarial  fever.  This 
typho-malarial  or  faecal-malarial  fever  has  always  had  seasons 
of  exacerbation :  during  some  years  assuming  a  mild  form,  at 
others  a  most  severe,  the  mortality  increasing  with  the  severity 
of  the  type. 

"  The  earlier  years  of  the  existence  of,  this  colony  have  been 
marked  by  seasons  of  extreme  unhealthiness,  especially  so  in 
1807,  1809,  1812,  1815,  and  1819.  In  1823,  yellow  fever  was 
epidemic,  commencing  in  the  earlier  part  of  the  year,  the 
so-called  '  healthy  or  dry  season/  and  running  on  through  the 
early  rains,  and  ending  with  the  '  heavy  rains.' 

"  In  1825,  yellow  fever  again  became  epidemic,  and  out  of  a 
known  902  persons  attacked  with  that  fever,  263  succumbed. 

"  In  1829,  during  the  months  of  April  and  May,  Sierra  Leone 
was  again  visited,  and  yellow  fever  then  confined  itself 
principally  (as  in  the  present  instance  May  and  June  1884) 
to  the  lower  levels  of  the  town.  This  epidemic  was,  however, 
stated  to  be  most  prevalent  during  the  blowing  of  the  westerly 
winds  and  the  falling  of  the  heavy  rain.  It  is  recorded  that 
out  of  150  Europeans  attacked  with  this  fever,  11  perished. 

"In  1837,  yellow  fever  commenced  amongst  the  Europeans 
in  the  month  of  April,  but  many  very  suspicious  cases  of 
endemic,  remittent,  or  the  so-called  African  fever  occurred 
during  the  month  of  January,  and  2  cases  died  having  distinct 
black  vomit.  In  March,  yellow  fever  declared  itself  amongst 
the    Europeans    in    Freetown,    and    the   first    case    occurring 


FREETOWxN  OUTBREAKS  153 

amongst  the  troops  was  on  nth  May  1837.  The  disease  is 
distinctly  stated  to  have  declined  with  the  maturity  of  the  rains, 
and  gradually  decreased  with  the  saturation  of  the  ground  and 
the  atmosphere  with  moisture  until  it  finally  ceased  by  almost 
imperceptible  and  indefinable  lines  merging  again  with  the 
ordinary  endemic  remittent,  from  which  nearly  all  cases 
recovered.  In  October  the  disease  broke  out,  but  not  in  so 
malignant  a  form,  and  finally  disappeared  in  December. 

"In  1838,  yellow  fever  appeared  in  February  and  ended  in 
March. 

"  In  1839,  a  severe  form  of  remittent  fever  caused  the  death 
of  6  officers  at  Tower  Hill.  During  the  months  of  July,  August, 
and  September,  every  man  of  the  Royal  African  Corps  suffered, 
and  the  mortality  amongst  that  corps  is  stated  to  have  been 
appalling.  There  were  7  officers  of  the  Royal  Navy  and  13 
seamen  attacked  with  yellow  fever,  and  all  died. 

"In  1S45,  yellow  fever  got  amongst  the  crews  of  H.M. 
squadron  at  anchor  in  the  Roquelle  River.  The  Eclair  sailed 
from  here  on  the  23rd  July  and  90  of  her  crew  perished  from 
yellow  fever.  One  case  died  in  September  from  malignant 
remittent  fever. 

"  In  1847,  yellow  fever  was  epidemic  in  Freetown  during  June, 
July,  and  August,  and  the  '  rainy  season'  was  noted  for  great 
heat  with  little  rain,  only  38.45  inches  falling,  followed  during 
rains  by  days  of  extreme  heat. 

"  In  1859,  there  was  no  rain  until  April,  May,  June,  which  was 
then  recorded  as  very  slight.  Yellow  fever  was  epidemic  in 
Freetown,  and  carried  off  160  Europeans  during  this  year. 

"  In  1865,  yellow  fever  again  appeared,  and  was  epidemic  in 
Freetown. 

"In  1 866,  yellow  fever  was  again  prevalent.  During  the  first 
quarter  of  the  year  there  was  no  rain.  Between  the  month  of 
April  and  the  2nd  of  October  100  Europeans  had  died  of  yellow 
fever. 

"  In  1872,  the  fevers  appeared  to  have  been  of  a  malignant 
type  during  the  months  commencing  May  and  ending  in 
December.  In  December  there  were  9  persons  attacked 
with  yellow  fever — 6  died.  The  average  death-rate  for  this  year 
has  been  rated  at  250  per  1000." 


154    CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

Mortality. — The  following  are  the  names  of  the  fatal  cases 
taken  from  the  report,  occurring  amongst  Europeans  and 
West  Indian  soldiers  who  died  from  pernicious  remittent  enteric 
or  typho-malarial  fever,  and  yellow  fever,  residing  in  Rawdon 
Street,  Westmorland  Street,  and  Howe  Street,  also  in  other 
localities,  with  a  brief  history  of  their  illness  during  the  months 
of  May  and  June  : — 

"  The  first  case  amongst  the  Europeans  was  that  of  Mons. 
Loire,  set  twenty-four.  He  was  taken  ill  on  6th  May  and  died 
on  1 6th  May.  His  case  was  one  of  the  typho-malarial  type. 
He  had  some  abdominal  tenderness  and  frequent  vomiting  of 
dark  coloured  slimy  matter ;  flushed  face  and  bright  eyes ;  his 
temperature  never  went  below  1030  F. 

"  Our  colleague,  Dr  Hart,  residing  in  Westmorland  Street, 
came  from  the  western  district  on  Sunday,  nth  May,  ill, 
after  an  absence  of  three  days.  His  temperature  up  to  the 
day  he  left  for  England  kept  constantly  at  1040  F.  He  had 
some  vomiting  resembling  coffee  grounds,  pain,  and  diarrhcea. 
He  was  delirious  at  times,  and  when  he  left  we  had  but  small 
hopes  of  his  recovery.  He  died  at  sea,  on  board  the  s.s. 
Calabar,  on  29th  May  1884,  off  Madeira.  His  case  was  one 
of  the  enteric  or  typho-malarial  type.  He  was  a  strong  man, 
and  this  may  account  for  the  long  time  he  was  ill.  From 
evidence  we  have  since  received,  the  doctor  had  convulsive 
fits,  twenty-nine  in  number,  after  all  fever  had  left  him.  The 
purser  of  the  ship  died  from  fever,  and  was  buried  the  same 
day.  It  is  reported  that  he  was  in  chronic  ill-health  and 
consumption. 

"  Mr  Walter  Maxwell,  an  agent  of  Messrs  Lothian,  Williams, 
and  Company,  residing  also  in  Westmorland  Street,  was  taken 
ill  on  10th  May,  and  died  on  20th  May.  He  vomited  inces- 
santly, but  had  no  diarrhcea.  He  ultimately  had  congestion  of 
the  brain  and  paralysis  of  his  vocal  organs.  He  refused  all 
medicines,  food,  and  stimulants.  His  cry  was  '  I  am  going  to 
die.'  He  was  a  hard  drinker  and  from  the  beginning  he 
caved  in. 

"  Mr  Donevein,  a  clerk,  living  in  the  same  house  as  Mr 
Maxwell,  residing  also  in  Westmorland  Street.     His  tempera- 


SYMPTOMATOLOGY  155 

ture  ranged  from  1020  to  104-6°.  Taken  ill  on  7th  and  died  on 
nth  June. 

"  Mr  Lambert  was  the  sixth  case.  He  was  a  clerk  of  the  Mata- 
cond  and  North  Western  Trading  Company,  and  I  have  never 
seen  a  man  sick  who  was  neglected  as  this  poor  fellow.  His 
illness  was  only  three  days,  and  his  temperature  during  the 
whole  time  never  went  below  104°  F. 

"  Mr  Moran,  a  man  who  was  dismissed  from  the  Matacond 
and  North  Western  Trading  Company  was  admitted  into  the 
Colonial  Hospital  on  the  afternoon  of  17th  June,  and  died  on 
the  1 8th  at  10.40  p.m.  This  case  was  one  of  delirium  tremens 
and  fever  distinctly  of  the  yellow  fever  type." 

Case  VIII. — Brief  extract  of  the  case  of  Lance-corporal  W. 
Wood,  2nd  West  India  Regiment,  aet.  twenty-two  years,  a  coloured 
man  admitted  into  the  Station  Hospital,  Sierra  Leone,  on  27th 
May,  suffering  from  enteric  fever  or  typho-malarial,  and  who 
died  on  25th  June  1884.  On  admission  he  had  all  the  symptoms 
of  ordinary  African  remittent  fever,  complained  of  pains  in  the 
back,  head,  and  limbs,  with  a  temperature  of  102  to  103°  F.  For 
several  days  his  temperature  seldom  fell  lower  than  ioi°F. 
and  rose  to  105-4°  on  the  evening  of  the  fourth  day  in  hospital 
and  the  fifth  of  his  illness.  He  now  appeared  gradually  to 
improve,  and  the  temperature  shortly  fell  to  normal.  On  the 
evening  of  5th  June,  he  had  a  sudden  rise  of  temperature  to  102°. 
The  tongue  was  very  red  at  the  tip  and  edges,  and  he  complained 
of  gripping  pains  in  his  bowels.  The  eyes  were  bright,  the  face 
flushed  and  anxious  looking,  and  he  stated  his  head  ached 
badly,  and  his  condition  was  such  that  enteric  fever  was  now 
diagnosed.  He  was  watched  with  great  care  and  everything 
done  for  him,  and  for  a  few  days  he  appeared  to  improve.  On 
14th  June  he  had  a  relapse,  arid  the  temperature  rose  in  the 
evening  to  105-2°,  and  remained  in  that  condition  during  the 
night,  until  the  early  morning  visit,  when  it  was  again  found  to 
be  105-2°,  but  fell  during  the  morning  to  102-4.°  His  condition 
now  became  serious.  On  the  morning  the  temperature  was 
102-4°  and  fell  again  in  the  evening  to  101-4°.  His  sleep  during 
the  night  was  much  broken  and  disturbed.  He  became  very 
restless,  wandering  in  his  mind,  and  attempted  frequently  to 


156     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

get  out  of  bed.  His  bowels  were  twice  freely  moved,  the 
evacuations  being  very  offensive,  and  the  urine  was  voided 
in  small  quantity  and  contained  traces  of  albumin.  On  the 
25th  he  showed  distinct  symptoms  of  failure  of  the  heart's 
action.  He  had  twitchings  of  the  fingers,  and  picked  the  bed- 
clothes ;  there  was  muttering  delirium,  and  he  became  quite 
unconscious  after  a  short  attack  of  convulsions,  with  squint- 
ing, and  twitching  of  fingers  and  lips.  He  expired  on  20th 
June.  The  post-mortem  showed  disorganisation  of  the  liver, 
kidneys,  heart,  and  spleen,  with  an  ulcerated  condition  of  the 
bowels,  enlargement  of  the  mesenteric  glands,  and  deep  red 
well-defined  ulcers  of  the  Peyers  patches  and  the  solitary  glands. 
The  colon  was  not  ulcerated.  Cause  of  death  :  remittent  fever, 
enteric  or  typho-malarial  fever. 

Typical  case  of  yellow  fever  in  a  native  of  the  West  Indies. 
A  black  man. 

Case  IX. — Report  on  the  case  of  R.  Codrington,  No.  2544, 
Private  2nd  West  India  Regiment.  Died  of  yellow  fever  on  the 
25th  June  1884  at  Sierra  Leone. 

"  This  man  reported  sick  at  the  Station  Hospital  on  the  23rd 
June  1884,  and  stated  that  he  was  suffering  from  'fever.'  His 
temperature  was  1020  and  his  bowels  were  confined.  He  was 
ordered  Sulph.  Quinine  gr.  xv,  and  a  diaphoretic,  also  a  purga- 
tive of  Calomel  gr.  v,  Pulv.  Jalap,  Co.  gr.  xxx,  and  detained  for 
the  night.  He  stated  on  this  occasion  that  he  had  suffered 
from  '  fever '  every  evening  for  some  days  previous  to  his 
reporting  sick. 

"  On  the  morning  of  the  24th  was  seen  at  7.30  A.M.  He 
complained  of  feeling  very  weak.  His  temperature  was  ioo°. 
His  tongue  was  covered  with  a  white  fur,  and  was  red  at  the 
tip  and  edges.  His  conjunctivae  were  tinged  with  yellow.  He 
also  suffered  from  frontal  or  orbital  pain  and  flying  pains  over 
the  abdomen.  During  the  night,  about  12  P.M.,  his  bowels  had 
been  well  moved,  he  stated.  When  I  first  saw  him  he  said  he 
had  a  great  pain  in  his  head.  I  prescribed  a  poultice  to  loins, 
together  with  hot  fomentation  to  abdomen,  and  suitable  diet. 
Next  saw  him  at  10  A.M.  the  same  day,  and  on  going  to  his 
bedside  I  noticed  in  the  chamber  pot  by  his  bed  some  black 


SYMPTOMATOLOGY  157 

fluid  which  he  said  he  had  just  vomited.  I  now  drew  the  atten- 
tion of  P.M.O.  Surgeon  J.  J.  Lamprey,  A.M.D.,  to  the  case,  as  I 
suspected  yellow  fever,  and  he  agreed  with  me.  It  was  a  most 
suspicious  case.  He  had  passed  some  urine  before  I  came  into 
the  ward,  but  unfortunately  it  had  been  thrown  away.  I  now 
ordered  his  urine  to  be  carefully  kept  until  I  saw  him  later  on 
in  the  day.  I  gave  him  a  diaphoretic  and  a  purgative  of 
sulphate  of  soda,  in  lukewarm  water.  I  also  ordered  the 
fomentation  to  be  continued.  At  3  P.M.  I  again  visited  him, 
and  noted  that  he  was  suffering  from  a  peculiar  nervous 
twitching  of  the  fingers,  and  that  the  conjunctivae  were  of  an 
intensely  yellow  colour,  and  the  eyes  looked  very  brilliant.  I 
found  he  had  not  passed  any  water  since  my  last  visit,  so  I 
passed  a  No.  9  gum  elastic  catheter,  and  drew  off  about  10  oz. 
of  high-coloured  offensive  urine. 

"  On  examination  of  this  fluid  it  gave  an  acid  reaction,  and 
on  testing  the  specific  gravity,  it  only  registered  -1014.  On  the 
addition  of  pure  nitric  acid  I  got  a  most  distinct  ring  of  albumin, 
and  on  heat  and  nitric  acid  being  applied,  the  urine  became 
almost  solid.  His  bowels  had  not  been  moved.  I  continued  the 
fomentations,  and  also  ordered  him  an  enema  to  which  was 
added  ol.  Terebinthinae,  this  treatment  having  been  recom- 
mended by  Professor  Aitken  and  all  other  authorities  on  the 
subject.  I  gave  him  also  during  the  day  weak  brandy  and 
water  with  dram  doses  of  ol.  Terebinth.  He  appeared  to  be 
better  at  7  P.M.  from  this  treatment  and  inclined  to  sleep.  He 
subsequently  fell  asleep  at  5  A.M.  on  the  25th  day.  He  suddenly 
awoke  and  jumped  out  of  bed.  He  was  got  into  bed  by  the 
orderly  in  charge,  and  then  became  comatose.  I  saw  him  at 
7  when  he  was  in  this  condition ;  breathing  was  stertorous  and 
heart's  action  very  feeble.  He  could  not  be  got  to  swallow 
anything.  At  8.30  he  had  another  black  vomit,  and  almost 
immediately  breathed  his  last. 

"  In  conclusion  I  may  mention  that  this  man  was  in  the  habit 
of  visiting  parts  of  the  town  which  I  believe  is  called  Soldiers 
Town,  and  where  the  most  insanitary  state  of  things  exist.  In 
my  humble  opinion  (and  that  of  my  brother  medical  officers  in 
the  garrison  also)  I  may  state  that  I  am  convinced  that  it  was  a 
true  case  of  yellow  fever,  and  the  appearance  of  the  eyes,  the 


158     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

pain  in  frontal  and  orbital  regions,  coupled  with  the  intense 
pain  in  the  region  of  the  kidneys,  the  presence  of  albumin  in 
the  urine,  and  the  pain  over  the  liver,  all  tend  to  bear  out  my 
diagnosis. 

"  I  may  mention  that  at  7.30  A.M.  on  the  25th  (to-day)  there 
was  suppression  of  urine,  and  the  bowels  had  not  acted  after 
the  enema  given  on  the  evening  of  the  24th,  that  is  to  say,  the 
fluid  injected  came  away  unchanged." 

A.  Hickman  Morgan, 
Surgeon,  A.M.D. 

Certified  true  copy, 

J.  J.  Lamprey,  A.M.D., 
Senior  Medical  Officer, 

West  Africa. 

CASE  X. — A  brief  extract  of  the  case  of  Sister  Theonite 
(Barbe  Tuntag),  set.  thirty  years,  a  resident  nun  in  the  convent 
and  school-house  in  the  Roman  Catholic  Mission  in  Howe 
Street,  where  she  contracted  fever  early  in  the  month  of  May. 

"  Some  bright  rose-coloured  spots  appeared  on  her  skin,  and 
she  complained  of  pain  in  the  head,  back,  and  limbs.  There 
was  very  little  fever,  and  she  attended  to  her  duties.  On 
1 8th  June  she  went  to  bed  and  complained  of  great  pain  in 
the  region  of  the  stomach.  She  did  not  improve  and  her  condi- 
tion became  seriously  worse.  She  discharged  from  the  bowels 
on  26th  June,  a  large  quantity  of  blood.  She  suffered  very 
great  pain  all  over  the  abdomen.  She  became  delirious  and 
died  on  Friday  morning,  27th  June  1884.    ■ 

"  The  death  of  Barbe  Tuntag  was  due  to  enteric  fever,  or  that 
form  of  it  complicated  with  malaria  known  as  typho-malarial 
fever. 

"The  sanitary  surroundings  at  Howe  Street  and  in  the 
Roman  Catholic  school-house  and  convent  are  highly  defective, 
and  the  system  of  sewage  disposal  is  very  bad. 

"The  other  members  of  this  mission  have  suffered  during 
the  present  season  from  repeated  attacks  of  remittent  fever,  and 
two  are  at  present  suffering  from  a  low  form  of  malarial  fever, 
contracted  in  these  infected  localities." 


SYMPTOMATOLOGY  159 

CASE  XI. — Mrs  Hagar  Palmer,  aged  twenty  years,  a  native  of 
Sierra  Leone,  residing  at  Lumley  Street,  died  on  25th  June 
of  yellow  fever  as  reported  by  Dr  Davies. 

CASE  XII. — Mr  Charles  James  Ryder,  aged  nineteen  years,  a 
European  clerk  at  Messrs  Pickering  &  Berthoud,  residing  at 
Howe  Street,  died  on  28th  June  of  yellow  fever. 

"  The  extreme  sick  rate  and  mortality  from  fever  amongst 
the  '  native  population,'  occurring  during  the  months  of  May 
and  June  in  Freetown,  and  falling  upon  a  great  number  of  the 
inhabitants  and  attacking  many  persons  at  the  same  time  with 
fever  and  pain  in  the  bowels,  bleeding  from  the  gums  and 
vomiting,  in  some  cases  black  in  colour,  has  been  a  disease 
taking  the  form  of  the  so-called  '  Sierra  Leone  fever,'  and  more 
severe  in  type  than  has  been  experienced  for  some  years  in 
this  city. 

"  The  death-rate  since  January  has  been  estimated  from  the 
'burial  records'  at  about  35  per  1000,  or  4  per  cent,  of  the 
entire  population.  The  registrar-general's  return  shows  for 
May  and  June  alone  no  less  than  19  deaths  amongst  the 
resident  natives  ;  and  this  is  the  more  remarkable  since  very  few 
of  these  have  been  authenticated  by  '  medical  certificate,'  and 
the  people  have  been  left  to  make  a  report  themselves  as  to  the 
'cause  of  death,'  according  to  their  own  judgment,  thereby 
proving  the  endemic  of  a  fever  by  exposing  a  very  obvious 
knowledge  of  its  more  fatal  symptoms." 

3.  Account  of  the  1900   Outbreak   of  Yellow  Fever  at  Bathurst 
by  Dr  Chichester 

Dr  Chichester,  who  attended  the  cases  in  the  outbreak, 
furnished  the  following  notes  and  most  interesting  comments. 
His  comments  are  all  the  more  interesting  for  he  was  probably 
unaware  of  the  Cuban  experiments  which  had  only  just  been 
announced.     He  states  : — 

"  Perhaps,  and  not  improbably,  in  this  case  mosquitos  were 
the  agents  responsible  for  the  yellow  fever  spreading  from  its 


160     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

original  centre.  It  is  worthy  of  note  that  all  the  cases  (with  one 
exception)  occurred  on  the  front  street  of  the  town,  the  street 
most  infested  with  mosquitos,  and  in  people  who  slept  without 
mosquito  nets,  or  with  nets  in  a  bad  state  of  repair. 

"  The  one  exception  referred  to  occurred  at  the  Catholic 
Mission,  and  he  slept  without  any  net  at  all.  The  government 
officials  who  live  in  the  front  street  escaped,  but  they  are  careful 
about  their  nets.  All  the  European  houses  but  three  were 
attacked.  One  was  at  too  great  a  distance  for  the  flight  of  a 
mosquito,  all  the  Europeans  belonging  to  a  second  went  away  at 
the  first  outbreak,  and  the  third  which  was  close  to  the  house 
primarily  attacked,  escaped ;  and  I  don't  know  why,  as  everything 
was  favourable  to  an  outbreak. 

"The  history  of  the  epidemic  is  as  follows  : — On  18th  May 
official  news  arrived  stating  that  yellow  fever  existed  in  Dakar. 
The  date  of  its  first  appearance  there  I  do  not  know.  The 
French  ports  north  of  the  Gambia  were  at  once  quarantined, 
and  later  on  those  south  of  the  Gambia  were  also  placed  in 
quarantine,  when  it  became  known  that  St  Louis,  Casamance, 
and  Carabane  had  become  infected. 

"  Case  No.  i. — A  Syrian  came  before  me  on  23rd  May.  The 
patient  was  in  much  pain,  feverish,  and  had  a  headache.  I 
admitted  him  into  the  hospital  under  the  impression  that  he 
was  suffering  from  influenza  then  prevalent  in  the  town.  How- 
ever, next  morning  not  liking  the  appearance  of  the  case — he 
was  very  restless,  semi-unconscious,  had  yellow  tinging  of 
conjunctivae,  his  urine  was  albuminous — I  had  him  transported 
to  some  huts  erected  for  native  small-pox  patients.  He  died 
that  evening,  having  vomited  just  before  death  '  coffee  ground ' 
looking  matter.  I  took  all  precautions  as  if  it  had  been  a  case 
of  yellow  fever,  and  reported  it  as  death  from  fever  'of  a 
doubtful  nature.5 

"  Case  No.  2  was  an  inmate  of  the  same  house  in  which  the 
first  case  had  occurred.  He  was  attended  by  a  native  qualified 
practitioner,  who  certified  that  he  died  of  remittent  fever.  The 
practitioner  in  question  informed  me  that  it  was  an  undoubted 
case  of  malaria,  but  I  am  inclined  to  think  that  it  must  have 
been  a  case  of  yellow  fever.  His  death  occurred  on  7th  June, 
and  he  had  been  some  five  days  ill. 


BATHURST  OUTBREAK  161 

"  Case  No.  3  also  came  from  the  same  house.  He  was  attended 
by  the  doctor  above  mentioned,  and  I  only  heard  of  his  being 
ill  on  9th  June.  I  asked  permission  of  the  doctor  to  see  him, 
but  I  could  make  out  little  that  was  definite  at  the  time.  Beyond 
headache  and  fever  there  was  little  to  go  on.  No  definite 
previous  history  could  be  obtained,  and  the  urine  had  not  been 
examined,  but  I  took  a  slide  of  blood  and  found  no  malarial 
parasites.  The  next  day  I  was  called  in  consultation,  and  by 
this  time  the  case  had  begun  to  look  very  suspicious.  He  was 
in  a  semi-comatose  condition,  the  conjunctivae  were  slightly 
tinged,  the  urine  was  nearly  suppressed,  and  the  small  quantity 
drawn  off  was  highly  albuminous ;  liver  and  spleen  were  not 
enlarged  ;  tongue  was  covered  with  a  white  fur  and  red  round 
the  edges.  This  looked  to  me  very  like  yellow  fever,  and 
the  question  in  my  mind  was,  Was  I  sufficiently  sure  to  have 
the  place  put  in  quarantine? 

"The  patient  died  that  night,  and  a  post-mortem  next 
morning  removed  all  doubt  from  my  mind.  I  declared  it  a 
case  of  yellow  fever  and  communicated  the  fact. 

"  On  that  and  the  following  days  I  received  instructions  to 
have  the  house  closed  and  watched,  and  to  have  those  not 
attacked  placed  in  quarantine  on  the  other  side  of  the  river,  and 
to  have  any  other  Syrians  who  might  become  attacked  sent  to 
the  small-pox  huts. 

"  Case  No.  4,  also  from  the  house  in  Russell  Street,  died  in 
the  small-pox  hut  on  12th  June,  having  been  removed  thereto 
that  morning. 

"  Case  No.  5. — This  was  a  young  French  clerk  living 
some  150  yards  from  the  house  in  Russell  Street.  I  was  called 
to  see  him  on  15th  June,  and  was  informed  that  he  had  been 
ill  for  some  days.  It  was  an  undoubted  case  of  yellow  fever 
and  I  at  once  had  the  house  and  business  closed.  He  died  on 
the  16th  of  haemorrhage,  due  to  the  rupture  of  a  blood  vessel  in 
the  stomach  walls. 

"  Case  No.  6. — This  was  an  Englishman  about  forty-five 
years  of  age,  who  had  been  many  years  on  the  Coast.  He  had 
been  in  very  bad  health  for  some  time  previous  but  only  called 
me  in  when  he  found  that  he  was  becoming  much  worse.  He  had 
certainly  had  yellow  fever  when  I  saw  him  for  some  four  days. 


162     CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

Under  treatment  and  careful  diet  he  improved  a  little,  but  died 
of  heart  failure  on  the  19th. 

"  Case  No.  7. — This  case  occurred  on  16th  June  at  the 
Telegraph  Station.     It  was  a  mild  case  and  ended  in  recovery. 

"  Case  No.  8. — On  28th  June  I  was  called  in  to  see  a  lay- 
brother  at  the  Catholic  Mission  who  had  been  taken  suddenly 
ill  the  previous  day.  It  was  another  case  of  yellow  fever,  and 
the  attack  was  exceedingly  severe.  He  died  within  thirty-six 
hours  from  the  time  of  onset. 

"  Case  9. — A  long  time  elapsed  between  this  case  and 
the  last  case.  He  was  a  clerk  in  one  of  the  companies,  and  his 
work  lay  behind  the  cash  counter.  I  could  not  trace  how  he 
contracted  the  disease.  He  was  taken  to  the  old  Military 
Hospital  on  4th  August  and  died  on  the  6th. 

"  This  was  the  last  case. 

"  The  mortality  was  heavy — 8  cases  out  of  9  died. 

"  That  the  disease  did  not  spread  further  is  without  doubt 
due  to  the  action  of  the  local  authority,  and  the  European 
merchants  in  sending  away  from  Bathurst  all  the  Europeans 
that  could  be  spared.  More  than  half  of  the  European  popula- 
tion left  in  the  early  part  of  the  epidemic. 

"  Case  10. — A  clerk  in  the  employ  of  one  of  the  European 
houses,  arrived  in  Bathurst  on  nth  October.  He  came  from 
Mandina  Bar,  a  town  on  the  banks  of  the  river  some  thirty 
miles  distant,  through  which  passes  much  traffic  from  Casamance, 
Carraban,  and  the  surrounding  country.  Casamance  and 
Carraban  are  towns  in  French  territory,  in  which  yellow  fever 
has  appeared,  and  which  are  no  doubt  still  infected. 

"  On  13th  October  he  was  taken  suddenly  ill  with  fever,  very 
severe  pains  in  head,  loins,  and  limbs,  vomiting  though  not 
severe.  The  headache  pains  lasted  all  the  next  day  and  well  on 
into  the  third  day,  when  I  was  called  in.  The  vomiting  had  by 
that  time  ceased  for  some  twenty-four  hours.  When  I  arrived 
the  pain  had  much  decreased.  His  temperature  was  103-4°; 
face  a  little  flushed  ;  eyes  watery,  and  rapid  pulse.  His  bowels 
not  having  been  opened  for  some  days  I  gave  a  purge  which 
acted  well,  and  quinine  6  g.  hypodermically.  His  tongue  was 
clean.  No  tinging  of  skin  or  conjunctivae.  Next  morning 
I  found  about  12  per  cent,  albumin  in  his  urine,  and  day  by  day 


BATHURST  OUTBREAK  163 

the  percentage  increased,  until  on  the  sixth  day  it  amounted  to 
over  60  per  cent.  I  could  not  have  the  urine  kept  to  measure, 
but  the  patient  did  not  think  the  amount  passed  had  much 
diminished.  The  blood  was  examined  for  plasmodia,  but, 
beyond  a  few  found  at  the  first  examination,  I  could  find  none. 
Quinine  seems  to  have  caused  their  disappearance,  but  it  had 
no  effect  on  the  temperature  which,  from  the  day  [  first  saw 
him  up  to  the  day  of  his  death,  ranged  between  102-4°  and 
103-8°,  except  when  on  the  sixth  day  it  went  up  to  104°.  On 
each  day  he  was  given  6  g.  of  quinine  hypodermically, 
with  the  addition  on  the  sixth  and  seventh  day  of  strychnine 
and  digitalis  as  his  pulse  was  getting  weaker. 

"  On  the  fifth  day  the  tongue  began  to  be  coated  on  the 
surface,  keeping  clean  and  red  looking  round  the  edges ;  the 
eyes  were  more  suffused  and  beginning  to  assume  a  yellow 
tint. 

"  On  the  sixth  day  the  skin  began  to  assume  a  yellowish  tint 
and  the  patient  himself  noticed  it,  but  it  did  not  become 
marked.  The  pulse  rate  was  at  no  time  in  proportion  to  the 
temperature,  and  on  the  fourth  day  began  to  lessen  to  84,  y6,  and 
72.  On  the  fifth  day  it  again  increased  in  frequency  while 
lessening  in  force.  The  temperature  all  this  time  remained 
pretty  constant. 

"  On  the  seventh  day  he  began  to  get  weaker,  and  this 
increased  despite  the  free  use  of  stimulants,  and  he  died  on  the 
evening  of  the  eighth  day  of  his  illness. 

"  Delirium  was  not  present  till  the  last  twenty-four  hours. 
After  the  cessation  of  the  initial  pains  lie  constantly  expressed 
liimself  as  feeling  quite  well.  I  have  noticed  this  in  nearly  all 
the  cases  of  yellow  fever  I  have  attended. 

"  A  post-mortem  examination  was  made,  but  I  had  to  content 
myself  with  the  examination  of  the  stomach,  intestines,  liver, 
and  spleen,  owing  to  the  difficulties  in  my  way. 

"  Stomach. — The  coats  were  softened  and  swollen,  blood 
vessels  prominent,  and  some  mucus  of  a  chocolate  colour  was 
present.     No  coffee-ground  matter  was  found. 

"  Small  intestines. — Pretty  much  the  same  can  be  said  of 
them  as  I  have  said  of  the  stomach. 

"  Spleen. — Was  not  enlarged. 


164    CLINICAL  HISTORY  OF  VARIOUS  EPIDEMICS 

"Liver. — Slightly  enlarged,  hyperaemic,  and  the  spirit  in 
which  a  small  piece  has  been  preserved  soon  assumed  a 
greenish  colour. 

"  Post-mortem  staining  of  the  body  was  very  marked,  not 
only  in  dependent  parts  but  over  the  neck  and  chest,  front  of 
lower  part  of  abdomen,  and  all  over  the  limbs. 

"  Case  ii,  Mons.  Brunei. — Another  case  is  at  present  under 
treatment,  a  European  belonging  to  the  same  firm.  It  is  up  to 
the  present  a  mild  case ;  but  I  have  little  doubt  that  it  also  is  a 
case  of  yellow  fever,  and  that  it  was  contracted  at  Mandina  Bar 
whither  he  had  gone  to  take  an  inventory  of  the  stock  after 
the  death  of  the  man,  of  whose  case  I  have  just  given  the 
history." 

Dr  Chichester  describes  n  cases  and  9  deaths.  In  every 
probability  there  were  more  cases  which  passed  unobserved, 
for  a  death-rate  of  nine  in  eleven  is  abnormal ;  moreover, 
at  this  time  there  was  influenza,  and  the  evidence  shows 
that  the  senior  medical  officer  regarded  the  cases  as 
"  malignant  remittent  fever " ;  and  another  officer  made  the 
diagnosis  of  "  malaria."  It  is  clear,  therefore,  that  in  this  out- 
break, as  in  previous  ones,  a  considerable  amount  of  divergence 
of  opinion  took  place.  The  symptomatology  given  by  Dr 
Chichester  is  unmistakably  that  of  yellow  fever.  Faget's  sign 
was  present,  also  albuminuria,  black  vomit,  haemorrhages, 
jaundice ;  and  quinine  was  without  effect.  In  this  outbreak, 
as  in  innumerable  others,  segregation  of  the  non-immunes 
was  the  specific  prophylactic  measure.  Dr  Chichester  con- 
sidered Senegal  as  the  source  of  infection.  But  as  on  very 
many  previous  occasions  Senegal  considered  Bathurst  as  the 
source  of  infection,  it  is  very  probable  that  yellow  fever  was 
endemic  to  both. 


CHAPTER  X 

THE   SYMPTOMS   OF   SOME   OF   THE   CASES    OF    YELLOW   FEVER 
WHICH   HAVE   APPEARED   IN    WEST   AFRICA   IN    RECENT 

YEARS 

Saltpond  1895 
1.  Gold  Coast — 

22nd March. — Patient  taken  unwell ;  temperature  103° ;  pulse 
100 ;  headache;  vomiting;  symptoms  increased. 

2^rd  March. — Vomiting  increased  ;  suppression  of  urine  (two 
days). 

24M  March. — Temperature  99-8°;  pulse  80;  vomiting  and 
hiccough. 

2%th  March. —  Temperature  1030 ;  jaundice  appeared;  con- 
junctivae yellow  ;  delirium  ;  vomit  consists  of  brown  material. 

26th  March.  —  Temperature  105-8°;  pulse  60;  marked 
yellow  skin. 

28/A  March. — Vomited  brown  material;  also  a  cupful  of 
blood  ;  then  coma  and  death  ;  deep  yellow  colour  of  body. 

Notes  signed  by  Dr  Garland. 

The  diagnosis  made  in  this  case  is  "  remittent  fever."  It  is 
very  obvious,  however,  that  it  is  a  most  typical  severe  form  of 
yellow  fever.  The  notes  show  rapid  onset,  one  paroxysm  of  fever 
lasting  five  days,  and  terminating  fatally  ;  marked  Faget's  sign  ; 
suppression  of  urine  and  jaundice  developing  towards  the  end  ; 
no  remission.     This  can  be  no  other  disease  than  yellow  fever. 

The  first  case  of  diagnosis  of  yellow  fever  in  1897  : — 
Mr    A.,   aet.    twenty-two.      Disease,   yellow   fever.      Result, 
death.     Date  of  admission,  15th  May  1897. 


166      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

Patient,  a  healthy  young  man,  had  arrived  from  England 
about  two  months  ago  ;  was  taken  suddenly  ill  on  the  morning  of 
the  15th,  about  7  A.M. 

i$th  May. — Onset ;  had  been  feeling  out  of  sorts  during  the 
afternoon,  but  had  played  a  game  of  tennis  about  5  P.M. 

Symptoms. — Pyrexia  (about  1  to  3  P.M.)  headache ;  pain  (not 
severe)  in  limbs  and  nausea  ;  vomited. 

16th  May. — 9.30  A.M.,  had  little  or  no  sleep  during 
night.  Frequent  vomiting;  temperature  102-4°  (pulse  not 
counted).     7.30  p.m.,  temperature  103-4°  '■>  pulse  104. 

iStk  May. — Temperature  103-6° ;  pulse  84,  soft  and  weak. 

igtk  May. — 9.30  A.M.,  temperature  104°;  pulse  82,  and 
fairly  strong.  At  2.30  P.M.  again  slight  perspiration.  During 
the  day  he  passed  a  fair  quantity  of  bilious  urine  and  two  or 
three  blackish  liquid  motions. 

2.0th  May. — 3.15  A.M.,  temperature  103° ;  had  not  passed 
urine  for  nine  hours,  6.45  A.M. ;  9  A.M.,  temperature  103.40 ;  pulse 
105,  weak  and  unsteady  ;  slight  yellow  tint  in  skin  ;  black  vomit. 
Quinine  has  proved  absolutely  useless.  1 1  A.M.,  black  motion  ; 
11.20  A.M.,  after  twenty  minutes  much  discomfort,  thirst  and 
wandering  ideas ;  patient  became  gradually  weak  and  ceased  to 
take  anything ;  black  vomit  occurred  more  than  once ;  no 
further  passage  of  urine ;  hiccough  set  in. 

Remarks. — At  the  time  of  writing  these  notes  (25th  May 
1897)  I  am  informed  of  two  and  three  similar  cases  as  having 
occurred  recently  at  Cape  Coast.  The  case  is  similar  to  the 
epidemic  which  prevailed  at  Elmina  and  Cape  Coast  in  the 
early  year  of  1895.  That  was  during  the  height  of  the  hot  dry 
season.  The  present  meteorological  conditions  are  the  reverse. 
We  are  well  into  the  rains.  I  stated  in  my  report  on  a  similar 
case  in  Elmina  that  in  my  opinion  the  disease  is  yellow  fever. 
I  adhere  to  that  opinion.  W.  M.  E. 

Here  also  is  a  very  typical  case  of  yellow  fever;  sudden 
onset ;  high  temperature  ;  one  paroxysm  ;  Faget's  sign  ;  quinine 
no  effect ;  suppression  of  urine  ;  black  vomit. 

Another  case — diagnosis  yellow  fever,  1897. 

17th  June. — The  doctor  reported  temperature  105° ;  tongue 


GOLD  COAST  CASES  167 

coated ;  breath  very  foul ;  pains  in  stomach ;  temperature  in 
the  evening  1030 ;  pulse  104. 

iStk  June. — Icteric  tint  appeared  ;  temperature  102-6°;  pulse 
98  ;  later  icteric  tint  deepened  ;  vomits  distinctly  black  ;  motions 
also  black  ;  suppression  of  urine. 

19th  June. — Symptoms  as  before;  death. 

Elmina  1895 

Case  of  J.  S. — Diagnosis,  "  hepatic  fever." 

yd  March.  —  Great  prostration;  vomiting;  vomit  very 
black ;  coffee  grounds ;  eyes  yellow ;  skin  primrose  yellow ; 
suppression  of  urine ;  death. 

Case  of  E.  C.  C. 

i8tk  April. — Temperature  102-4°;  pulse  100;  intense  head- 
ache ;  backache  ;  nausea ;  epigastric  pain. 

igtk  April. — Temperature  103-4° ;  pulse  92. 

22nd  April. — Black  vomit ;  death. 

Post-mortem  examination  showed  liver  extremely  congested  ; 
kidneys  congested ;  stomach  containing  black  vomit ;  skin 
yellow. 

The  house  physician,  Dr  W.  M.  G.,  states  that  this  is  a 
suspicious  case  of  yellow  fever ;  the  same  as  Mr  S.  He  seems 
to  have  had  little  doubt  that  these  were  cases  of  yellow  fever. 

Cape  Coast  1902 

Case  OF  A.  N.,  set.  twenty-eight.     Diagnosis,  yellow  fever. 

1st  July. — Temperature  100-4°;  pulse  100 ;  skin  and  con- 
junctivae yellow;  albuminuria;  drowsy,  anorexia;  no  malarial 
parasites  found  in  the  blood. 

2nd  July. — Urine  bile  stained  ;  but  patient  feels  better. 

yd  July. — Feeling  very  much  better ;  took  solid  food  ;  this 
was  followed  by  black  vomit ;  skin  became  bright  yellow ; 
delirious,  then  coma. 

Afth  July. — Vomited  black;  and  later  pure  blood,  and  died. 

Post-mortem. — Skin  bright  yellow ;  liver  yellow ;  stomach 
and  intestines  deeply  congested. 

G.  L.  Barker. 


168      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

CASE  OF  Mr  V. — Diagnosis,  yellow  fever. 

\st July. — Temperature  102-2°;  pulse  76;  later  in  the  day 
temperature  103-8° ;  pulse  78  ;  later  82  ;  conjunctivae  commencing 
to  turn  yellow ;  urine  albuminous ;  at  the  end  of  day  passed  a 
tarry  stool. 

2nd  July. — Vomiting  set  in  ;  bilious  matter  :  delirious. 

^rd  July. — Vomit  black  ;  followed  by  blood  ;  very  persistent ; 
passed  a  tarry  motion  ;  coma,  then  death. 

Post-mortem  Notes. — Skin  yellow,  liver  yellow,  and  mottled 
with  red  ;  kidneys  congested,  stomach  congested,  and  containing 
black  fluid  similar  to  vomit ;  intestines  ditto. 

G.  L.  Barker. 

CASE  OF  A.  S.,  set.  twenty-five.  —  Diagnosis,  yellow  fever, 
March  1903. 

A.  S.,  European  clerk,  set.  twenty-five,  living  in  business 
house  in  native  quarter ;  ten  months  resident  in  Cape  Coast ; 
seen  23rd  March  1903;  temperature  102-4°;  pulse  quick;  face 
flushed  ;  urine  dark  colour ;  tongue  furred. 

2^th  March. — Bad  night,  pain  varies  ;  temperature  103-4°. 

2$th  March. — Temperature  101-5°  I  pronounced  catarrh  of 
stomach ;  intestine  discomfort ;  Dr  Rome  Hall  considered  that 
the  case  was  one  of  malarial  remittent  plus  acute  -  gastric 
enteritis,  in  fact  typho-malarial  remittent  fever.  On  same  day 
commenced  to  vomit  yellowish-green  mucus ;  much  depressed. 

26th  March. — Vomiting  ceased;  temperature  ioi-i°;  pulse 
60  ;  with  temperature  100-5  °  >  mental  depression. 

28^  March. — Temperature  ioo-8° ;  tongue  coated  with  dark 
brown  colour ;  sordes  very  marked ;  eyes  much  more  icteric ; 
breath  very  foul ;  pulse  depresses  as  before ;  could  not  see  any 
jaundice  ;  removed  to  hospital. 

2gth  March. — Temperature  at  6  a.m.  99-4° ;  pulse  70.  The 
pulse  for  the  next  forty-eight  hours  remains  slow,  and  did  not 
increase  with  the  rising  temperature ;  eyes  very  yellow ;  slight 
general  jaundice  ;  vomited  once. 

30//Z  March. — Temperature  102-2° ;  urine  alb. ;  vomit  bilious  ; 
temperature  100-5°  I  pulse  87. 

2,ist March. — Jaundice  increased  ;  patient  apathetic.  "I now 
question  diagnosis." 


GOLD  COAST  CASES  169 

1st  April. — Jaundice  increased  ;  suppression  of  urine. 

2nd  April. — Jaundice  much  better;  temperature  102-7°;  pulse 
96;  vomited  brownish  material;  in  evening  blood-stained  material. 

Afth  April. — Urine  passed,  considerable  quantity  of  alb. ;  head 
brighter ;  patient  seemed  improving. 

^th  April. — General  primrose-yellow  colour  of  body. 

6th  April. — Purging;  temperature  1020 ;  pulse  128. 

Jth  April. — Death,  bringing  up  at  the  last  some  black  vomit. 

Dr  Rome  Hall  at  first  considered  that  he  had  a  case  of 
ordinary  malaria  fever  with  typhoid  symptoms.  The  disease  was 
not  blackwater  fever.  "  I  noted  that  .  .  .  ?  was  much  greater 
than  an  ordinary  remittent  malaria.  The  pain  and  uneasiness 
in  epigastrium  was  not  marked.  The  offensive  odour  was  most 
marked  in  this  case.  The  presence  of  albumin  in  urine  made 
me  question  my  diagnosis.  The  vomiting  set  in  late.  In 
bilious  remittent,  black  vomit  is  not  known.  The  P.M.  signs 
seem  to  me  universally  in  favour  of  yellow  fever. 

"  Yellow  fever  has  several  times  in  recent  years  been  recog- 
nised on  the  French  Ivory  Coast  and  in  Senegambia.  The  Ivory 
Coast  is  only  150  miles  or  forty-eight  hours  away  from  Cape 
Coast  by  the  coast  and  steamers,  and  at  the  present  moment, 
14th  April  1903,  we  are  quarantined  as  regards  the  Ivory  Coast 
against  yellow  fever.  The  first  steamer  with  the  quarantine 
flag  came  into  Cape  Coast  from  the  Ivory  Coast  in  the  last  week 
in  January,  and  since  that  date  there  has  been  landing  and 
other  communications.  The  Stegomyia  is  universal  in  the 
merchants'  tanks  and  in  the  water  tanks  of  the  natives.  Old 
writers  believed  that  slave  ships  carried  yellow  fever  from  the 
Guinea  Gulf.  Fantees  describe  malaria  bilious  remittent  fever 
amongst  themselves  as  Kondruku.  In  the  disease  Kondruku 
Fufu,  the  patient  usually  dies." 

G.  Rome  Hall,  S.M.O. 

Note. — I  have  received  the  following  letter  from  Dr  Savage 
in  confirmation  of  the  cases  of  yellow  fever  in  Cape  Coast : — 

Cape  Coast, 
20th  fune  1 9 10. 

"  I  have  the  honour  to  forward,  as  requested  in  your  telegram 
of  yesterday's  date,  the  Colonial  Hospital  Case  Book  containing 


170       THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

records  of  European  cases  during  the  years  1902  and  1903.  I 
have  been  in  private  practice  in  this  town  since  January  1902 
and  I  remember  well  the  deaths  of  the  European  Bank  Clerks 
recorded  in  the  Case  Book. 

"  These  deaths  caused  considerable  stir  at  the  time  at  Cape 
Coast.  Dr  Barker,  I  observe,  recorded  in  the  case  -  book  two 
of  these  cases  (Bertian,  25.  6.  02.  &  Brown,  29.  7.  02)  as 
Remittent  Fever  and  Pernicious  Fever  (?)  suspecting  the  case  of 
Veners  (4.  7.  02.)  alone  as  Yellow  Fever. 

"  Dr  Barker  I  knew  was  strongly  of  opinion  that  the  three 
cases  were  Yellow  Fever  cases  for  I  had  several  conversations 
with  him  at  the  time  on  the  cases. 

"  Dr  Rome  Hall's  case  of  Alfred  Smith  I  remember  very  well 
also.  Dr  Rome  Hall  had  not  the  least  doubt  that  the  case  was 
one  of  Yellow  Fever  and  he  was  kind  enough  to  send  me  at  the 
time  a  copy  of  the  clinical  record  of  the  case. 

"  I  may  remark  here  that  at  the  time  that  Dr  Barker  was 
attending  the  cases  at  the  Bank  I  was  in  attendance  on  Mr 
B.,  a  European  employee  of  Messrs  The  African  Association 
for  Bilious  Remittent  Fever.  The  local  residence  of  this  firm 
was  then  next  door  to  the  Bank  on  the  Salt  Pond  Road.  I 
kept  no  clinical  record  of  the  case,  but  I  remember  I  had  great 
difficulty  at  the  time  in  differentiating  between  Yellow  Fever 
and  Bilious  Remittent  Fever  as  the  diagnosis.  Mr  B.  recovered 
and  was  invalided,  and  the  last  time  I  heard  of  him  he  was 
somewhere  in  the  United  States  of  America. 

"  1  had  not  the  least  doubt  that  Dr  Barker's  cases  at  the 
Bank  were  cases  of  Yellow  Fever.  Some  time  after  Mr  B.'s 
recovery  I  urged  upon  Messrs  The  African  Association,  for 
whom  I  was  then  working  under  a  yearly  retainer,  to  remove 
their  quarters,  which  in  many  respects  were  insanitary,  to  a 
better  locality,  which  was  done  about  a  year  later,  but  not  until 
two  other  European  employees  of  theirs,  Mr  T.  B.  and  Mr  John 
A.  D.,  had  £died,  one  on  the  21st  March  1903  and  the  other,  a 
near  arrival,  on  2nd  May  1903.  These  two  cases  I  diagnosed 
as  Pernicious  Malarial  Remittent  with  cerebral  symptoms  and 
Non-Malarial  Remittent  Fever  respectively,  and  I  may  state 
here  that  the  duration  of  the  illness  was  above  5  or  6  days. 

"On  15th  October  1903,  the  firm  of  Messrs  The  African 


FREETOWN  1910  CASES  171 

Association  in  the  new  premises  to  which  they  had  removed 
lost  another  European  employee,  R.  G.  B.  by  name,  also  a  new 
arrival.  This  case  was  undoubtedly  one  of  Yellow  Fever. 
There  was  the  characteristic  black  vomit  of  Yellow  Fever  about 
the  3rd  or  4th  day  of  the  disease  and  most  abundant  just 
before  the  patient  died  :  the  conjunctivae  and  skin  were  yellow 
about  the  3rd  day  of  the  disease,  the  urine  was  loaded  with 
albumin :  the  pulse  was  full  and  bounding  for  the  first  two  or 
three  days  of  the  disease  and  markedly  soft  and  slow  about 
the  4th  and  5th  day  when  the  end  came. 

"  I  remember  sending  the  body  to  the  Colonial  Hospital 
Mortuary  for  post-mortem  examination  and  the  appearances 
were  characteristic  of  Yellow  Fever. 

"  Since  Mr  B.'s  death  Messrs  The  African  Association,  I 
believe,  have  not  lost  locally  a  European  employee,  nor  as  far  as 
I  know  has  the  Bank,  who  remain  in  the  same  quarters  that 
they  were  in  in  1902. 

"  I  did  not  keep  a  full  clinical  record  of  any  cases  but  I  was 
so  much  concerned  at  the  time  by  the  loss  of  so  many  Europeans 
and  of  so  many  patients  of  mine  that  the  cases  were  stamped  in 
my  memory  and  my  recollection  of  them  is  vivid." 

Dr  Elliott,  who  saw  many  of  the  cases  of  yellow  fever  at 
Saltpond  on  the  Gold  Coast,  lays  stress  upon  the  late  develop- 
ment of  icterus,  the  black  vomit,  and  the  tarry  stools,  and  the 
uselessness  of  quinine  in  helping  to  distinguish  yellow  fever 
from  the  malarial  group.  The  cases  which  he  published  in  the 
Journal  of  Tropical  Medicine  are  typical  of  yellow  fever. 

Dr  S.  O.  Browne  also  published  a  case  of  yellow  fever  which 
he  observed  at  Saltpond.  The  history  shows  sudden  onset,  a  fever 
of  one  paroxysm,  suppression  of  urine,  intense  black  vomit, 
lividity  and  yellow  colour  of  the  skin  after  death. 

2.  Symptomatology  of  the  Freetown  Cases  of  Yellow  Fever, 
19 10.     {Notes  furnished  by  Dr  Kennaii) 

Case  I. — 2nd  May. — A  Syrian,  set.  twenty-three,  stated  to 
have  been  taken  ill  with  fever  and  bleeding  from  the  nose. 

4th   May. — Admitted    into  Colonial  Hospital    at  9.45    a.m., 


172      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

with  temperature  102-6°.  Said  to  have  had  fever  and  slight 
haemorrhage  from  nose  on  2nd  inst.  On  the  4th  it  came  on 
with  increased  violence,  and  he  was  brought  to  hospital.  He 
was  in  a  dazed  condition,  his  skin  a  dirty  yellow  in  colour,  and  he 
was  very  restless.     The  bleeding  stopped  towards  evening. 

^th  May. — Had  copious  black  vomiting,  and  a  stool  of  the 
same  colour.  The  vomiting  continued,  and  just  before  death  at 
2.30  P.M.  on  the  same  day  (5th),  he  bled  profusely  from  the 
mouth,  nose,  and  bowel.  His  blood  was  examined,  and 
contained  no  parasites  and  no  mono-nuclear  leucocytes.  No 
post-mortem  examination  held,  as  relatives  refused  permission. 

Case  II. — 6th  May. — A  Syrian  male,  aged  fifteen  years 
admitted  to  Colonial  Hospital  at  6  P.M.  His  temperature  on 
admission  was  1040,  skin  pronouncedly  yellow,  and  sclerae  the 
same.  Eyes  injected  and  bright,  patient  restless  and  delirious. 
Bowels  were  apparently  empty  as  enemata  had  no  effect.  No 
previous  history  obtainable. 

yth  May. — Patient  passed  a  restless  night,  and  his  tempera- 
ture in  the  morning  was  103-8°.  No  malarial  parasites  were 
found.  He  had  "black  vomit,"  and  died  at  11  A.M.  on  the  7th, 
Post-mortem  refused  by  friends.  (Both  cases  were  under  the 
care  of  Dr  Burrows,  M.O.  Comment. —  It  is  unfortunate  that  in 
both  these  cases  there  is  no  precise  information  as  to  the  date 
of  onset  of  the  illness  ;  in  the  first  case  it  might  have  been  on  2nd 
May.  In  the  second  case  I  am  of  opinion  that  the  onset  of  the 
attack  was  at  least  three  days  prior  to  6th  May,  that  is  he  was 
probably  taken  ill  on  2nd  May,  so  that  when  admitted  into 
hospital  he  was  in  his  sixth  day  of  illness.  I  have 'no  hesitation 
in  concluding  that  both  were  cases  of  severe  yellow  fever. 

Case  III. — Mr  H.  H.  T.,  Englishman,  forty-one  years,  living 
in  Garrison  Street. 

gt/i  May. — Had  a  "  touch  "  of  fever  with  headache. 

iO#&  May. — Had  a  rigor  temperature  104°,  and  violent  head- 
ache.    These  symptoms  continued  with  more  or  less  severity. 

nth  May. — Examined  by  doctor ;  temperature  104-8°  at  5 
P.M. ;  headache  very  severe  ;  loin  pain  was  much  complained  of; 
face  flushed  and  skin  of  a  yellowish  red  almost  brawny  colour. 


FREETOWN  CASES  173 

\2th  May. — Patient  removed  to  the  Nursing  Home.  His 
blood  was  examined  independently  first  by  Dr  Kennan  at 
about  6  P.M.  and  by  Dr  Burrows  twelve  hours  afterwards,  and  no 
parasites  (malarial)  were  found.  He  had  had  little  or  no  Quinine 
before  the  blood  examination.  Urine  highly  albuminous,  with 
trace  of  bile,  acid  and  scanty.  Temperature  continued  high 
sinking  slowly  from  1040  on  admission. 

13th  May. — Temperature  102-4°;  in  the  evening,  passed  a 
fair  night,  but  symptoms  of  collapse  were  noticed. 

i^th  May. — Temperature  99°  at  7  A.M. ;  condition  was  grave, 
respirations  54  per  minute,  but  pulse  was  slow  and  fairly  full. 
The  lungs  became  congested,  and  there  was  rattling  respiration 
which  continued  all  day.  Temperature  reached  103°  in  the 
rectum,  and  the  patient's  condition  became  worse.  He  had  "  black 
vomit"  (small)  at  6  p.m.,  and  at  8.15  P.M.  there  was  a  profuse 
discharge  of  "  tarry "  liquid  from  the  mouth  and  nose,  and  the 
patient  died. 

Note. — The  tongue  was  coated  with  a  greyish  fur  and  breath 
was  very  foul ;  the  tongue  was  clean  at  the  edges.  The  aspect  of 
the  patient  on  admission  to  the  Home  was  the  subject  of 
spontaneous  remark  by  the  nursing  sister,  who  very  aptly 
described  the  eyes  as  peculiarly  "  bright  and  sharp  looking." 

Post-mortem  examination  made  by  Dr  Burrows,  in  presence 
of  Drs  Kennan  and  Renner,  at  7  A.M.  on  15th  May. — Brain 
(weight,  3  lb.  4  oz.),  not  unduly  congested,  but  marked  oedema  of 
the  pia-arachnoid  over  the  frontal  region.  Heart  (weight 
1 3  oz.)  fatty,  and  muscle  substance  friable  and  "  dry."  Valves, 
yellowish  colour.  Lungs  (right,  20  oz.) ;  (left,  17  oz.), 
congested  posteriorly.  Spleen  (18  oz.),  soft,  friable,  almost 
diffluent.  Liver  (72  oz.),  enlarged,  sharp  edges  and  "  fatty  "  (dull 
yellow).  Right  kidney,  6§  oz. ;  left,  5  oz.,  both  markedly 
congested.  Stomach  contained  dark  brown  mucous  fluid, 
extremely  well  marked  injection  of  arborescent  vessels  in  wall. 
Intestines  contained  fluid  similar  to  that  in  stomach. 

(Mr  Taylor,  who  was  an  "  old  coaster,"  had  arrived  in  the 
Colony  from  his  last  leave  in  October  previous.) 

Case  IV. — Case  of  G.  R.,  reported  by  Dr  Burrows.  Syrian 
male,  aged  about  twenty-five  years,  living  at  26  Kissey  Street. 


174      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

iSth  May. — Complained  of  lassitude,  yawning,  and  stretching. 

\gth  May. — Tired  feeling  exaggerated. 

20th  May. — Bowels  moved  freely ;  no  malarial  parasites 
found,  but  patient  had  taken  quinine  regularly ;  temperature 
ioi°;  no  headache;  no  vomiting;  malaise  and  great  thirst, 
with  a  griping  pain  in  stomach. 

2\st  May. — Temperature  102'  ;  at  8  A.M.,  bowels  acted; 
temperature  103-6°  in  evening ;  feels  better. 

22nd May. — Temperature  103  in  the  morning;  tongue  very 
foul  and  furred  ;  temperature  in  the  evening  103° ;  patient  very 
distressed  and  uneasy ;  epigastric  tenderness ;  had  sweated  a 
little  in  afternoon  ;  complains  of  sleeplessness. 

22>rd  May. — Temperature  103°  in  the  morning  ;  felt  much 
better  ;  conjunctivae  slightly  jaundiced  ;  looked  rather  tired  and 
worn  out ;  temperature  104°  in  the  evening  ;  pain  and  uneasiness 
increased ;  two  natural  loose  motions  passed ;  removed  to 
hospital  ;  patient  was  given  nourishment,  which  he  took  at  short 
intervals  fairly  well ;  he  was  restless  up  to  10  P.M.,  and  then 
slept  well  for  the  rest  of  the  night. 

2^th  May. — Temperature  102-6°  in  the  morning ;  strained  a 
good  deal  to  pass  urine — about  6  oz.  passed ;  and  bladder 
being  distended,  it  was  emptied  by  catheter  and  1  pint  of 
dark  urine  (acid  and  one-tenth  albumin)  was  drawn  off;  patient 
was  drowsy  and  distinctly  jaundiced  ;  his  face  pinched  and 
"  worried  looking  "  ;  he  had  alternate  phases  of  quiet  and  restless- 
ness during  the  forenoon,  and  began  to  become  comatose 
shortly  after  2  o'clock  ;  pulse  was  full  104,  but  became  slower  as 
day  wore  on  ;  urine  1  pint  drawn  off  by  catheter ;  temperature 
at  7  P.M.,  10 1 G  in  axilla,  but  skin  felt  cool  and  clammy  ;  patient 
was  restless  all  night,  became  delirious,  and  finally  sank  into  a 
condition  of  "coma  vigil." 

2$th  May. — Temperature  rose  rapidly  to  105-4°  between 
5  and  6  A.M.,  and  patient  became  quiet,  and  died  at  6.30  A.M. 

Post-mortem  examination,  25th  May  19 10,  9.30  A.M. 

Yellowish  skin  and  scleras,  mottly,  bluish,  spotty,  rash,  chiefly 
limbs  and  scrotum  ;  liver  yellow,  "  box- wood,"  exsanguine ; 
spleen  soft,  not  enlarged  ;  kidneys  slightly  congested,  large ; 
stomach  contained  large  quantity  black  fluid,  congested ;  small 
intestines  contained   a  quantity   of  fluid    resembling   that   in 


FREETOWN  CASES  175 

stomach ;  large  intestines  contained  grey,  small  faeces  ;  bladder 
contained  about  i  pint  of  urine ;  lungs  healthy ;  pericardium 
some  excess  straw-coloured  fluid  ;  sub-pericardial  haemorrhage 
in  left  interventricular  groove ;  heart  normal,  valves  yellowish, 
and  yellowish  serum  clot  in  chambers. 

Weight  of  organs. — Heart,  7  oz.  ;  right  lung,  16  oz. ;  left 
lung,  170Z. ;  right  kidney,  5  oz.  ;  left  kidney,  6i  oz. ;  liver,  40  oz. ; 
spleen,  5  oz. 

Note. — Mr  Rebiez  had  arrived  in  Freetown  from  Dakkar 
between  two  and  three  weeks  before  the  onset  of  illness. 

CASE  V. — Reported  by  Dr  Burrows. 

26th  May. — An  old  coaster  who  had  returned  from  England 
early  in  the  year  19 10  had  two  short  and  distinct  rigors,  soon 
followed  by  severe  headache.  He  at  once  took  10  g.  quinine, 
and  followed  them  with  25  g.  more  within  twenty-four  hours  ; 
temperature  that  night  1030  F. 

27/^  May. — Temperature  ranged  from  99°  to  ioo°  all  day  ; 
headache  severe  and  continuous. 

2%th  May. — Passed  four  copious  dark  green  stools  in  morning, 
as  result  of  purge ;  temperature  1010.  Was  seen  by  doctor  for  the 
first  time  same  afternoon  ;  temperature  still  1010 ;  tongue 
coated,  fissured,  and  very  foul ;  blood  examined  showed  no 
parasites  and  no  mono-nuclear  leucocytosis ;  no  albumin  in  the 
urine  ;  temperature  1040  at  midnight,  and  cardiac  distress  slight. 

2C)th  May. — About  2  A.M.  was  very  restless  and  agitated  ; 
bowels  moved  twice — "pea-soupy"  and  foul ;  temperature  ioi°; 
blood  re-examined,  no  malarial  parasites ;  urine  contained 
albumin  ;  tongue  dry  ;  covered  with  brownish  fur  ;  temperature 
103°  at  noon,  and  at  5  p.m.   1030 ;  removed  to  nursing  home. 

30//Z  May. —  Temperature  102-6° ;  restless;  urine  one-sixth 
albumin ;  stools  copious  ;  grey  liquid  and  excessively  foul ; 
temperature  102°  at  6  P.M ;  breathing  became  very  laboured; 
pulse  94  to  100  per  minute ;  was  freely  stimulated  during 
night. 

31^  May. — Temperature  fell  to  99-4°  at  2  A.M.;  pulse 
running  about  100  per  minute  ;  temperature  dropped  to  normal 
at  3  A.M.,  and  contained  so  for  rest  of  day;  urine  highly 
albuminous ;    took   all    nourishment    and    stimulants   without 


176      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

trouble.  At  noon  cardiac  distress  increased  ;  urine  suppressed  ; 
patient  more  or  less  comatose ;  twitching  of  muscles  of  face  and 
neck.  At  3.50  A.M.  patient  had  "  black  vomit,"  and  died.  Seen 
immediately  after  death,  the  face  was  a  bright  yellow,  but  this 
speedily  disappeared  ;  bluish  discolorations  about  neck,  arms, 
penis,  and  scrotum. 

Post-mortem  was  made  at  about  5  P.M.,  limited  to  examina- 
tion of  the  stomach  and  liver.  The  former  contained  a  fairly- 
large  quantity  of  almost  black  fluid,  the  stomach  wall  was 
congested,  the  mucous  membrane  was  swollen  and  patchily 
injected.  The  liver  was  greatly  congested,  with  no  "  box-wood  " 
appearance  about  it.  The  small  intestines  contained  similar 
material  to  that  in  the  stomach.  The  conjunctivae  were  slightly 
yellow,  but  yellowness  in  the  skin  could  scarcely  be  said  to 
be  present. 

CASE  V. — Report  on  post-mortem  on  body  of  European 
named  C.  H.,  Captain,  Mercantile  Marine,  9th  June  1910,  by 
Captain  Webb,  R.A.M.G 

The  body  is  that  of  a  well-nourished  man.  Had  been  in  the 
Colony  one  and  a  half  years.  There  is  marked  general  yellow 
discoloration  of  the  skin  and  also  of  the  conjunctivae  ;  patches  of 
ecchymosis  on  the  skin  of  the  legs,  and  darker  coloration  of 
the  scrotum  and  dependent  parts ;  an  incision  through  the 
abdominal  parieties  shows  the  abdominal  fat  stained  deep 
yellow. 

The  liver  was  retracted  slightly  under  the  costal  edge,  and 
showed  a  yellow  mottling  through  the  peritoneal  covering. 
This  latter  stripped  off  extremely  easily,  and  the  liver  substance 
itself  was  very  soft,  breaking  down  on  very  slight  pressure. 
The  whole  of  the  liver  showed  fatty  degeneration  and  a  box- 
wood appearance. 

The  stomach  showed  ecchymosis  under  the  peritoneal 
surface,  and  contained  a  dark  and  markedly  bloody  fluid  about 
3  oz.  The  mucous  lining  was  deeply  congested,  and 
numerous  petechial  points  were  present  over  the  whole  of  the 
surface.  The  small  intestines  were  distended  and  had  ecchymosis 
on  their  surface,  and  contained  thick  black  tarry  material. 

The  spleen  was  somewhat  enlarged,  very  friable  and  con- 


FREETOWN  CASES  177 

gested.      The   pericardium   contained   about    2    oz.    of  deeply 
stained  yellow  fluid. 

The  heart  was  covered  with  a  thick  layer  of  fat,  especially  on 
its  right  and  posterior  surfaces.  The  mesentery  was  very  fat 
and  stained  yellow.     The  bladder  was  full. 

Comment. — From  the  post-mortem  appearances  the  case  was 
in  all  probability  yellow  fever. 

CASE  VI. — "  Private,  R.G.A.,  died  in  the  military  barracks 
at  Tower  Hill,  on  16th  July  1910,  and  by  the  courtesy  of 
Colonel  Sutton,  S.M.O.,  R.A.M.C,  I  was  afforded  an  opportunity 
of  seeing  specimens  removed  at  the  post-mortem  examination, 
and  the  clinical  notes  on  the  case.  Death  was  undoubtedly  due 
to  yellow  fever"  (Dr  Kennan). 

Case  VII. — Maisie  Hayer,  female  Syrian,  aged  about  thirty- 
five  years,  lived  in  Fourah  Bay  Road.    Reported  by  Dr  Mayhew. 

i"/ 'th  July. — -Stated  to  have  been  taken  ill. 

2.2nd  July. — First  seen  by  the  doctor  ;  temperature  104-2° ; 
anxious  expression  ;  slightly  jaundiced  ;  pulse  about  100  ;  com- 
plaining greatly  of  cramping  pains  in  arms  and  legs ;  given 
10  gr.  bihydrochlor.  of  quinine  intramuscularly;  had  had  attacks 
of  fever  on  and  off  for  some  time ;  present  illness  began  three 
days  previously  ;  had  been  vomiting,  with  looseness  of  bowels ; 
removed  to  P.C.M.  Hospital ;  given  further  injection  of  quinine, 
bihydrochlor.  iogr.;  tongue  clean;  tenderness  in  epigastric  region  ■ 
vomited  once  in  evening  grey  liquid,  not  black ;  temperature 
remained  104-2°  ;  put  under  mosquito  net;  passed  per  rectum 
what  looked  like  undigested  rice ;  cramping  pains  severe. 

2^rd  July. — Temperature  began  to  come  down  in  early 
morning  at  4  A.M.,  103-6°;  at  8  A.M.  to  ioo° ;  no  sweating; 
patient  became  collapsed  ;  12  midday,  temperature  99° ;  patient 
vomited  black  material  resembling  coffee  grounds  three  times  at 
8  A.M. ;  patient  not  having  passed  urine  since  admission,  a 
catheter  was  passed,  and  about  8  oz.  bile-stained  urine  was  drawn 
off  containing  much  albumin  ;  at  2  P.M.  patient  was  obviously 
dying  ;  cold  extremities  ;  pulseless ;  gasping  respiration.  She 
died  about  5.45  P.M.  In  a  blood  film  no  malarial  parasites 
were  seen. 

M 


178      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

Post-mortem. — The  stomach  contained  a  quantity  of  black 
fluid ;  the  mucous  membrane  was  studded  with  punctiform 
haemorrhages.  The  liver  was  greyish  in  colour,  but  the  light 
was  too  bad  to  make  out  much  about  it.  Although  the  patient 
had  been  dead  only  an  hour,  post-mortem  "  staining  "  was  well 
marked  on  the  back. 

CASE  VIII. — Acting  on  information  received,  that  a  Syrian 
had  died  suddenly  on  the  night  of  26th  July  19 10,  and  that 
application  for  a  grave  had  been  made,  and  that  he  had  not 
been  attended  by  a  doctor,  I  communicated  with  the  coroner 
who,  after  he  had  made  inquiry,  ordered  the  body  to  be  removed 
to  the  mortuary,  where  a  post-mortem  examination  was  made 
by  Dr  Renner,  M.O.  The  result  showed  that  death  was  due  to 
yellow  fever,  and  the  verdict  of  the  jury  was  given  accordingly. 
The  Syrian's  name  was  Nazmadeen  (male,  adult).  He  had 
lived  in  a  house  on  the  same  side  of  Fourah  Bay  Road,  and  a 
few  houses  removed  from  that  in  which  the  previous  case  of 
Maisie  Hayer  (Syrian  woman)  had  occurred,  and  which  ended 
fatally  in  Princess  Christian  Mission  Hospital  on  the  22nd  inst., 
that  case  having  its  onset  on  or  about  the  17th,  i.e.,  the  day 
after  that  on  which  Private  died  in  Tower  Hill  Military 
Barracks,  his  case  being  the  first  of  the  "  recrudescence  "  series. 

R.  H.  Kennan,  Ag.  P.M.O. 

Case  IX. — A  native  clerk,  aged  twenty-three,  residing  at 
Henry  Street,  W.  Freetown. 

27th  July. — Stated  he  had  been  taken  ill,  suffering  from  an 
attack  of  fever,  with  much  pain  in  chest  and  back  regions ;  also 
that  he  attended  the  hospital  on  the  same  day  as  an  out- 
patient in  the  Government  official  department. 

2%th  July. — He  went  home  and  the  symptoms  were  aggra- 
vated, so  that  he  was  unable  to  report  himself  to  out-patients' 
department  that  morning.  This  was  reported  to  the  doctor,  who 
went  directly  to  see  him.  On  this  day  he  began  to  have 
vomiting  very  frequently,  so  that  he  could  scarcely  keep  down 
anything  in  the  way  of  medicine  or  nourishment. 

29M  July. — Visited  by  the  doctor,  who  ordered  him  to  go 
into   the   hospital.     On   admission   temperature    104°  F..;  com- 


FREETOWN  CASES  179 

plains  of  the  pain  over  abdominal  region,  especially  over  liver 
and  stomach.  States  that  the  vomiting  was  troublesome,  and  that 
it  was  all  of  liquid  consistence,  yellowish  green  in  colour ;  but 
since  coming  in  he  has  not  vomited.  Bowels  fairly  free,  pulse 
1 20,  and  respirations  28;  tongue  furred;  eyes  very  much 
jaundiced  ;  general  condition  well. 

31^  July. — Patient  feels  a  good  deal  better  this  morning; 
the  temperature  99-4°  ;  states  that  the  pain  in  chest  and 
abdomen  is  a  little  better  too,  but  in  the  back  is  still  going  on, 
though  not  so  severely  as  yesterday.  Slept  fairly  well;  urine 
high  coloured  and  full  of  deposit ;  urine  examined;  sp.  gr.  1025  ; 
reaction  strongly  acid,  highly  albuminous ;  bile  also  found. 

1st  August. — Temperature  normal ;  complains  of  much  pain 
over  the  liver,  and  weakness  ;  eyes  very  much  jaundiced  ;  urine 
very  high  coloured  and  greenish,  with  much  deposit ;  was 
slightly  delirious  and  restless  during  the  greater  part  of  the 
night ;  vomited  once,  but  only  the  clear  mixture  which  was 
given  to  him  ;  had  one  stool  of  a  yellowish  colour. 

2nd  August. — Temperature  1040  F. ;  slight  delirium  ;  restless 
and  weak ;  urine  stained  bed-clothes  dark  yellowish-green 
colour;  pulse  140;  respiration  30;  death,  preceded  by  a  slight 
convulsion. 

Post-mortem  examination. — Friends  allowed  a  limited 
examination  only.  An  incision  3  ins.  long  was  made  in 
middle  line  of  epigastrium ;  the  stomach  was  brought  out, 
opened,  and  large  quantity  of  coffee-ground  fluid  was  emptied 
from  it.  A  portion  of  stomach  was  removed  towards  the 
cardiac  end,  the  mucous  membrane  was  found  to  be  marked 
out  with  arborescent  congested  capillaries.  Liver :  a  small 
portion  of  liver  was  removed ;  this  was  typically  boxwood 
colour. 

Case  X. — Mr  C,  European  employee,  set.  twenty-five,  living 
in  Rowden  Street.  Has  lived  in  the  Colony  one  year  and  three 
months.  Takes  quinine  regularly  and  has  had  malarial  fever. 
He  had  charge  of  a  shop  in  Kissy  Street.  Patient  was  taken  ill 
with  chill,  headache,  pains  in  back  and  legs,  vomiting.  On  the 
third  day  of  illness,  headache  and  pains  more  severe,  temperature 
103°,   pulse    120,   no  jaundice,   no    albuminuria,   no   epigastric 


180      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

tenderness,  no  malarial  parasites  in  the  blood,  conjunctivae  con- 
gested.    Subsequently  patient  improved  and  recovered. 

Suspicious  cases. — In  addition  to  the  well-marked  cases  of 
yellow  fever  described  above,  and  about  which  there  could  be 
no  question,  there  also  occurred  a  certain  number  of 
suspicious  cases  which,  knowing  that  Stegomyia  existed  in 
Freetown,  might  have  been  the  mild  form  of  the  disease.  I 
have  stated  elsewhere  that  this  is  of  common  occurrence  in  all 
outbreaks  of  yellow  fever,  but  naturally  most  frequently  met 
with  in  those  countries  where  the  authorities  were  not  on  the 
lookout  for  the  disease.  The  following  four  cases  are  examples ; 
there  may  have  been  others. 

6th  June. — A  child  was  taken  ill  and  developed  a  tempera- 
ture of  1040,  but  recovered. 

\st  July. — Mr  A.  S.,  a  European,  was  taken  ill  with 
lassitude ;  body  pains ;  headache ;  malarial  parasites  were 
absent,  and  there  was  no  albuminuria.  On  the  following  day 
the  temperature  was  101-2°.     Patient  recovered. 

2^th  June. — Case  of  Dr  J.  W.,  arose  feeling  unwell;  head- 
ache; white,  became  later  more  severe;  temperature  ioo°  at  7 
P.M. ;  loss  of  appetite  ;  some  nausea. 

26th  June. — Temperature  at  2  A.M.,  1020 ;  and  at  7  A.M.,  1040 ; 
later  104-6°,  with  a  pulse  rate  of  94 ;  marked  photophobia ; 
some  restlessness  and  vomiting. 

27//*  to  29th  June. — Patient  became  convalescent. 

Case  of  R.  W. 

20th  June. — Taken  ill,  with  symptoms  of  loss  of  appetite  and 
temperature  ioi°. 

23rd  June. — Temperature  rose  to  ioi°  and  103°.  No 
malarial  parasites  were  found  in  the  blood ;  nor  was  there 
albuminuria ;  later,  however,  slight  jaundice  and  gastric 
symptoms  developed,  but  this  subsequently  passed  off. 

I  lay  no  stress  upon  these  cases,  because  now  that  the 
outbreak  is  over  it  would  be  quite  impossible  to  prove  anything 
definite  one  way  or  the  other.  But  there  did  occur  some 
months  previously  in  Freetown  cases  which,  when  looked  back 
upon  in  the  light  of  the  symptomatology  of  the  well-marked 


GOLD  COAST  CASES,  1910  181 

cases,  might  in  the  opinion  of  the  medical  men  who  attended 
them  have  been  genuine  well-marked  types  of  the  disease. 

These  cases  are  of  the  greatest  importance,  because  if  yellow 
fever,  they  show  that  infection  was  present  in  Freetown  prior 
to  the  outbreak  in  1910.  If  it  is  agreed  that  yellow  fever  was 
endemic  in  Freetown,  there  is  nothing  unusual  in  cases  appear- 
ing prior  to  the  1910  outbreak.  At  a  meeting  of  the  medical  men 
present  in  Freetown,  held  at  Government  House  on  4th  August 
1910,  it  was  stated  that  in  the  light  of  recent  events  a  fatal  case 
which  had  been  diagnosed  as  one  of  phosphorous  poisoning 
in  November  1909  might  in  reality  have  been  a  case  of  yellow 
fever.  The  patient  had  no  albuminuria,  nor  were  malarial 
parasites  found  in  the  blood.  Black  vomit  was,  however,  one  of 
the  more  suspicious  symptoms  ;  the  temperature  was  1030. 
Another  case  was  mentioned,  in  which  in  1908  the  diagnosis  of 
gastric  ulcer  was  made  in  the  case  of  a  Syrian.  The  patient  in 
question  vomited  a  large  quantity  of  what  appeared  to  be 
undigested  blood,  and  died  the  same  night.  The  doctor  who 
attended  this  case  now  thinks  that  it  might  have  been  a  case  of 
yellow  fever.  Indeed,  the  opinion  was  expressed  by  many  of 
those  present  at  the  meeting  that  cases  of  yellow  fever  had  been 
mistaken  for  other  diseases  in  the  past,  and  that  in  all 
probability  the  disease  was  endemic. 

Histories  of  Yellow  Fever  Cases  at  Secondee,  Axim,  and  Sawmills, 
1910.     (Notes  furnished  by  Drs  Rice  and  Ralph.) 

Case  I.— Mrs  C. 

\2tk  April. — Taken  suddenly  ill,  with  severe  headache  and 
prostration,  and  temperature  1050. 

13th  April. — Visited  by  Dr  Ralph  ;  temperature  1050. 

i6tli  April. — Jaundice  developed,  also  vomiting;  the  vomit 
was  greenish  in  colour,  and  scattered  through  it  were  black 
specks  like  "  fly  spots."  There  was  no  albumin  in  urine. 
Pulse  84;  temperature  ioi°-io2°. 

17th  April. — Temperature  104-4°;  jaundice  general. 

\Zth  April. — The  motions  were  clay-like;  no  albuminuria; 


182      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

vomiting  diminished ;  jaundice  deeper ;  pulse  78 ;  bile  in 
urine. 

20th  April. — Temperature  ioi-2°-i02°;  conjunctivae  deep 
yellow,  also  whole  body. 

21  st  April. — Temperature  ioi°-io2°  ;  vomiting  almost  ceased  ; 
feels  better. 

2^rd  April. — Temperature  97°-98°. 

2^th  April. — Temperature  98°-99°. 

2^th  April. — Temperature  gy°-gg° ;  taking  solid  food,  but 
jaundice  still  very  deep. 

27/^  April. — Temperature  98°-99-4°. 

2Stk  April. — Sailed  for  England,  but  jaundice  still  marked. 

Comments. — No  albuminuria  or  suppression  of  urine  developed. 

Comment. — The  kidneys  in  this  case  do  not  appear,  there- 
fore, to  have  been  affected.  The  jaundice  increased,  and  the 
slowing  of  the  pulse  is  no  doubt  associated  with  this  symptom. 
The  fly  spots  in  the  vomit  indicate  the  very  early  commence- 
ment of  congestion  of  the  stomach ;  they  did  not,  however, 
deepen  and  pass  into  black  vomit. 

Case  II.— Mr  R.  C. 

27th  April. — Taken  suddenly  ill ;  temperature  1040;  frontal 
headache ;  vomiting. 

28//Z  April. — Examined  by  Dr  Ralph ;  temperature  ioi-8°- 
102-8°.  Conjunctivae  congested;  photophobia;  tongue  furred; 
pulse  80 ;  headache  became  severe  and  persistent ;  vomited  ; 
urine  scanty;  no  albumin  ;  tinge  of  jaundice. 

29//Z  April. — Temperature  1010;  headache  persists;  intra- 
muscular injection  of  9  gr.  of  quinine  given  without  effect ; 
vomiting  troublesome  and  showed  the  black  specks ;  urine 
contained  a  trace  of  albumin  ;  pulse  now  78  ;  restless. 

30th  April. — Patient  was  able  in  the  morning  to  attend  to  a 
little  business  and  to  sign  his  name  to  a  letter.  Very  little 
urine  was,  however,  passed  during  the  day.  At  10.30  A.M.  had 
a  convulsion,  sank,  and  died.  The  "jaundice,  which  had  been 
present  from  the  beginning,  became  much  more  marked  after 
death,  the  body  being  a  dark  brown  colour." 

Comment. — In  this  case  the  kidneys  appear  to  have  been 
early  severely  affected;  the  headache  and  vomiting  were  more 


GOLD  COAST  CASES,  1910  183 

severe  and  persistent.  It  is  therefore  a  more  severe  case  than 
the  previous  one.  It  was  the  case  which  caused  the  medical 
officer,  Dr  Ralph,  to  consider  that  he  was  dealing  with  yellow 
fever.     Quinine,  it  will  be  noted,  had  no  effect. 

Note. — In  previous  years  Mr  R.  C.  had  lived  at  a  consider- 
able distance  from  the  native  town.  Immediately  prior,  however, 
to  his  fatal  illness  he  had  lived  in  the  native  town,  and  no  doubt 
became  whilst  there  infected  with  yellow  fever. 

Case  III. — Mr  W.,  white  man. 

8tk  May. — Taken  suddenly  ill  in  the  early  morning  ;  tem- 
perature 1050 ;  severe  headache ;  some  vomiting.  At  8  A.M. 
seen  by  Dr  Ralph.  He  showed  the  following  symptoms : 
intense  headache ;  face  very  flushed ;  eyes  injected ;  tongue 
furred  ;  great  prostration  ;  there  was  no  albuminuria. 

gth  May— Fair  night;  slight  vomiting;  two  intramuscular 
injections  of  9  gr.  each  of  quinine  given  without  any 
marked  effect,  temperature  being  1030 ;  urine  very  scanty  and 
albuminous. 

lOtk  May. — Temperature  varied  from  98-4°  to  ioo-8° ;  in  the 
evening  pulse  72  ;  troublesome  hiccough  now  set  in  with  vomit- 
ing ;  the  vomit  contained  black  specks ;  muscular  twitchings 
appeared  and  the  jaundice  deepened  markedly  ;  sclerae  deep 
yellow ;  convulsions  increased  in  frequency,  and  at  1 1  P.M. 
patient  vomited  a  large  quantity  of  black  vomit. 

Comment. — This  case  is  more  severe  than  the  preceding  one  ; 
the  kidney  is  markedly  affected,  the  jaundice  was  intense,  and 
the  pulse  became  slow,  showing,  no  doubt,  profound  change  in 
the  liver ;  the  gastric  symptoms  became  more  intense,  ending  in 
black  vomit  on  the  third  day. 

Note. — Mr  W.  had  visited  the  bungalow  occupied  by  Case  II., 
but  so  had  another  gentleman,  who  did  not  get  it.  There  was 
the  other  possibility  that  Mr  W.  contracted  the  infection  at  the 
warehouse,  close  to  which  there  was  a  native  house. 

CASE  IV. — Rev.  H.  B.,  white  man,  missionary,  living  in 
commercial  town. 

gth  May. — Patient  seen  by  Dr  Ralph,  and  complained  of 
headache  ;  lassitude  ;  temperature  normal,  but  in  the  afternoon 
it  rose  to  1030 ;  pulse  90  ;  eyes  congested. 


184      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

loth  May.  —  Constipation ;  intense  headache  ;  jaundice 
appeared  ;  intramuscular  injection  of  quinine. 

i  \th  May. — Injection  of  quinine  was  repeated,  but  without 
effect  on  temperature  ;  pulse  now  80 ;  albumin  appeared  for  the 
first  time ;  jaundice  deepened ;  towards  end  of  day  patient 
became  restless  and  delirious. 

12th  May. — Temperature  1030,  pulse  80;  black  specks 
present  in  the  vomit;   urine  more  albuminous. 

\^th  May. — Symptoms  progressed,  and  at  midnight  black 
vomit  ejected  by  the  pump-like  action  of  the  stomach,  there 
being  no  effort.  At  4  A.M.  the  following  morning,  14th  May, 
patient  died. 

Comment. — This  case  is  like  the  preceding  one.  The  kidneys, 
liver,  and  stomach  appear,  however,  to  have  been  more  severely 
affected. 

Post-mortem  made  twelve  hours  after  death. — Body  well 
nourished ;  surface  stained  pale  yellow,  with  well-marked 
petechiae  about  the  neck  and  shoulder ;  rigor  mortis  still 
present ;  body  slightly  warm ;  conjunctivae  stained  a  deep 
saffron  colour.  Heart  and  Lungs. — Beyond  staining  of  valves 
nothing  abnormal.  Liver. — Slightly  enlarged ;  pale  yellow  on 
section  ;  but  was  more  congested  than  some  of  the  other  cases  ; 
considerable  fatty  degeneration  was  present.  Kidneys. — Showed 
haemorrhages  under  capsule,  which  stripped  readily,  but  these 
were  more  marked  at  bases  of  pyramids ;  no  haemorrhage  into 
pelvis.  Spleen. — A  little  swollen ;  no  marked  microscopic 
change.  Stomach. — Contained  black  fluid,  with  marked  conges- 
tion of  the  mucous  membrane.  Lntestines. — Lower  part  of  small 
intestine  contained  black,  tarry  matter ;  small  haemorrhages 
could  be  seen  under  the  peritoneum. 

Case  V. — Mr  W.  R.,  white  man,  living  in  commercial  town, 
close  to  the  market. 

gth  May. — Dr  Ralph  called  in  and  found  patient  complaining 
of  headache;  pains  in  the  limbs;  temperature  1040 ;  pulse  84 ; 
later,  face  flushed  ;  eyes  injected  ;  edges  of  tongue  red. 

10th  May. — Passed  fair  night ;  temperature  varied  from 
1020  to  1050  at  6  P.M. ;  pulse  72  ;  no  albuminuria  ;  was  given  two 
intramuscular  injections  of  quinine,  which  had  no  effect. 


GOLD  COAST  CASES,  1910  185 

nth  May. — Vomited  during  the  night;  black  specks  in  the 
vomit;  temperature  I04°-I05°;  delirium  marked;  tried  to 
get  out  of  bed  (shouting) ;  albumin  appeared  for  the  first 
time. 

\2th  May. — Temperature  1050;  heart  failing;  albuminuria 
more  marked ;  then  suppression  of  urine  for  eighteen  hours 
before  death ;  the  delirium  was  marked  throughout  the  night ; 
constant  black  vomit  was  present ;  marked  convulsions  took 
place  five  hours  before  death. 

Comment. — A  severe  case  like  the  two  preceding  ones ; 
kidneys  and  stomach  more  profoundly  affected. 

CASE  VI. — Adam,  a  native  black  man;  post-mortem  14th 
May  1910;  said  to  have  died  the  previous  night,  13th  May; 
tall  muscular  man;  rigor  mortis  passing  off;  conjunctivae  deep 
yellow ;  some  "  black  vomit "  on  table  escaped  from  mouth. 
Heart. — Beyond  slight  dilatation  was  healthy ;  valves  deeply 
stained.  Lungs. — Old  adhesions  over  right  base  and  about 
upper  portion  of  lower  lobe ;  congested  at  bases,  but  crepitant. 
Liver. — A  little  enlarged  ;  almost  lemon  colour  on  section  ; 
tissue  appeared  to  be  softer  than  normal ;  I  think  fatty 
degeneration  was  present.  Spleen. — Enlarged  ;  capsule  thick- 
ened ;  tough  on  section.  Kidneys. — Showed  small  haemorrhages 
in  the  cortex ;  not  very  marked  under  capsule,  which  stripped 
readily.  Stomach. — Contained  "  black  vomit."  Lntestines. — 
Lower  part  for  a  short  distance  contained  black,  tarry  mucous 
matter.  All  tissues  deeply  stained,  including  cartilages  and 
ribs. 

CASE  VII. — Kroo-boy,  of  the  Gold  Coast  Machinery  and 
Trading  Co.  Brought  to  the  mortuary  dead  on  16th  May 
1910.  Post-mortem  made  about  twelve  hours  after  death. 
Body  well  nourished,  muscular ;  conjunctivae  stained  deep 
yellow  colour.     All  tissues  were  of  a  saffron  tint. 

Heart. — Valves  showed  the  general  staining,  otherwise 
normal.  Lungs. — Old  adhesions  on  both  sides,  but  crepitant 
throughout.  Liver. — Slightly  large  on  section,  of  a  pale  yellow 
colour,  very  suggestive  of  fatty  degeneration.  Kidneys. — 
Showed     haemorrhages    in    the    cortex,    chiefly     at    base    of 


186      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

pyramids.  Spleen. — Enlarged,  capsule  very  thick  and  tough, 
adherent  to  abdominal  wall.  No  marked  change  beyond 
toughness  on  section.  Stomach. — Contained  small  quantity 
of  dark,  almost  black  fluid,  with  marked  congestion  of  mucous 
membrane.  Intestines. — In  lower  part  contained  black  tarry 
matter.  There  were  small  red  patches  under  the  peritoneum, 
which  appeared  to  be  haemorrhages.  Congestion  of  mucous 
membrane  not  so  marked  as  in  the  stomach. 

CASE  VIII.  —  Mr  B.,  living  in  commercial  town,  in  an 
inferior  class  hotel,  was  under  the  care  of  Dr  Hayford,  but 
owing  to  the  necessary  evacuation  of  that  part  of  Secondee  at 
night,  he  slept  in  the  Colonial  Hospital  (part  of  which  has  been 
turned  into  a  dormitory)  on  the  17th  inst.  Dr  Ralph  first  saw 
him  on  the  morning  of  18th  May,  when  he  had  a  high  tempera- 
ture, but  would  persist  in  going  into  the  town.  He  returned 
at  2  p.m.  obviously  very  ill,  and  was  at  once  admitted  into  the 
hospital.  Temperature  103-8° ;  flushed  face  ;  marked  injection 
of  the  eyes,  which  were  very  bright  and  watery ;  tongue  furred, 
red  tip;  pulse  90,  full  and  hard  ;  temperature  ioi°  at  8  P.M. 

igtfz  May. — Urine  passed  during  the  night  contained 
albumin.  Conjunctivae  jaundiced.  Was  very  restless  and  did 
not  sleep  much.  Temperature  6  A.M.,  1010 ;  6  P.M.,  1010.  Pulse 
much  softer,  not  so  full,  70.  There  was  some  nausea,  and  he 
vomited  a  lot  of  milk,  but  no  sign  of  "  coffee  grounds."  Was 
restless  and  talkative  all  day,  gradually  getting  more  jaundiced. 
Constantly  trying  to  get  out  of  bed. 

20th  May. — Urine  contained  more  albumin.  Temperature 
6  AM.  1020,  6  P.M.  103° ;  pulse  better,  70.  He  was  very  rest- 
less and  excited  all  day,  but  slept  fairly  well  at  intervals. 

2 1st  May. — Very  restless  and  delirious  all  night.  Vomited 
at  intervals,  the  "  black  specks  "  in  vomit  much  more  pronounced. 
Urine  almost  solid  with  albumin.  Very  small  quantity,  about 
5  oz.,  passed  during  the  night.  Temperature  6  A.M.,  103° ;  6  P.M., 
half  an  hour  after  death,  104°.  He  was  very  delirious  and 
excited  all  day,  tearing  up  mosquito  net  and  blankets.  At 
the  end  vomited  large  quantity  of  "  black  vomit."  Jaundice 
gradually  got  deeper  all  day,  and  before  death  there  were 
petechias    about  the  neck  and  upper  part  of  trunk.     He  had 


GOLD  COAST  CASES,  1910  18  7 

slight  convulsion  at  the  end.  No  urine  was  passed  for  twenty- 
four  hours. 

Comment. — This  case  shows  very  well  the  increase  of  the 
gastric,  hepatic,  and  renal  symptoms. 

Post-mortem  made  on  23rd  May,  about  twelve  hours  after 
death.  Body  deep  yellow  with  petechiae  about  the  neck  and 
upper  part  of  trunk  ;  conjunctivae  deep  saffron  colour,  body  not 
well  nourished,  thin  and  spare.  Heart. — Valves  healthy,  stained 
colour.  Lungs. — Normal.  Liver. — Slightly  enlarged.  On 
section  pale  yellow,  seemed  tougher  than  normal.  I  consider 
fatty  degeneration  was  present.  Kidneys. — Haemorrhages  into 
cortex  very  small,  but  present  chiefly  at  the  base  of  pyramids  ; 
capsule  stripped  readily.  Spleen. — Enlarged,  soft.  Stomach. — 
Contained  "  black  vomit,"  marked  congestion  of  mucous  mem- 
brane.    Intestines. — Small  quantity  of  black,  tarry  matter. 

Case  IX. — Rev.  A.  T.  R.  B.  came  from  Accra  on  12th 
May  and  stayed  at  the  Mission  House. 

20th  May. — Patient  was  brought  to  the  hospital  at  5  P.M., 
semi-conscious,  in  a  hammock,  and  was  at  once  admitted ; 
temperature  1030.  There  was  no  complaint  of  headache,  only 
general  feeling  of  weakness  and  discomfort.  Given  phenacetin 
5  gr.,  to  be  repeated  in  half  an  hour  if  not  sweating,  with  hot 
lime  drinks.  This  started  a  profuse  sweat,  and  temperature  fell 
to  10 1. °  When  seen  late  in  the  evening  he  expressed  himself 
as  being  better;  no  albuminuria  ;  pulse  full  and  hard,  80. 

2\st  May. — Temperature  6  A.M.,  1010  ;  6  P.M.,  103-2°.  Was 
given  intramuscular  injections  of  quinine,  bihydrochloride  9  gr.,  at 
intervals  of  twelve  hours,  which  produced  no  effect  on  the  tempera- 
ture ;  faint  trace  of  albumin  in  urine ;  bowels  confined,  slight 
jaundice.  Was  quite  cheerful  and  comfortable  during  the  day, 
but  complained  that  light  hurt  his  eyes ;  pulse  not  so  hard,  76. 
During  the  night  began  to  complain  of  headache  and  was  a 
little  deaf.     More  albumin  in  urine,  which  was  very  acid,  102-2°. 

22nd May. — Temperature  6  A.M.,  102° ;  6  P.M.,  104-4°.  Late  in 
the  afternoon  mental  symptoms  developed.  Incoherency  and 
forgetfulness,  but  was  able  to  write  letters.  Bowels  open  three 
times;  stools  paler;  passed  only  12  oz.  of  urine  and  very 
little  with  the  stools. 


188      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

2^rd  May. — Temperature  6  A.M.,  1020;  pulse  72,  .weaker. 
Slept  fairly  well.  Bowels  open  during  the  night  but  very  little 
urine  passed.  There  was  a  little  vomiting  of  blackish  fluid. 
Jaundice  was  very  much  more  pronounced,  the  conjunctivae 
being  of  a  deep  yellow  colour.  In  spite  of  stimulants  his  heart 
gradually  failed,  and  he  died  at  10.30  A.M. 

Case  X. — Native,  post-mortem  examination  held  23rd  May. 
Wife  of  a  clerk  living  at  Essikadu.  Post-mortem  held  about 
sixteen  hours  after  death.  Well-nourished  healthy  woman ; 
considerable  enlargement  lower  part  of  abdomen ;  conjunctivae 
deep  yellow  colour. 

Lungs  and  Heart. — Normal,  all  tissues  stained  deep  yellow. 
Liver. — Slightly  large ;  yellow  colour  on  section ;  very  blood- 
less ;  looked  like  fatty  degeneration.  Stomach. — Contained 
small  quantity  of  black  fluid ;  mucous  membrane  congested. 
Small  intestines.  —  Lower  part  contained  blackish  mucous 
material  for  a  considerable  length.  Spleen. — A  little  enlarged, 
otherwise  normal  on  section.  Was  perhaps  a  little  tough. 
Uterus  very  considerably  enlarged ;  definite  haemorrhages  in 
both  ovaries ;  Fallopian  tubes  very  much  swollen  and  enlarged  ; 
fimbriated  extremities  much  congested.  The  patient  had  had 
a  miscarriage  (22nd  May)  previous  to  death  the  same  day. 

Case  XL — Mr  A.  H.  H.,  assistant  commissioner  of  police, 
arrived  in  Secondee  from  Accra  on  14th  May.  His  duties 
consisted  of  superintending  the  evacuation  of  the  declared 
infected  area  each  evening  at  5  P.M.  This  also  necessitated  a 
later  visit  to  see  that  there  were  no  Europeans  sleeping  in  the 
area. 

22nd  May. — Early  on  the  morning  he  was  awakened  by 
severe  frontal  headache,  pain  in  the  eyes,  and  photophobia  ; 
temperature  1030.  He  was  seen  by  Dr  Purkis  about  6.30 
A.M.  On  admission  to  the  hospital  his  temperature  was  103-4° ; 
pulse  full  and  hard  ;  no  albumin  in  urine. 

2-$rd May. — Temperature  in  the  morning  and  afternoon  was 
103° ;  pulse  90  full.  Still  had  persistent  headache ;  was  very 
restless  all  night,  but  dosed  at  intervals.  Intramuscular 
injection  of  quinine  bihydrochloride,  9  gr.,  was    given    at    10 


GOLD  COAST  CASES,  1910  189 

A.M.  and  repeated  at  9  P.M.,  but  had  no  effect  on  temperature. 
Stools  were  light  clay-coloured.  Had  slight  nausea  but  no 
actual  vomiting ;  slight  jaundice. 

24M  May. — Was  slightly  delirious  during  the  night  but 
slept  at  intervals;  vomited  after  a  cup  of  tea  at  6  A.M.  This 
contained  small  "  black  specks "  in  the  mucus  and  tea ; 
temperature  6  A.M.,  1030.  Passed  no  urine  during  the  night, 
but  a  specimen  obtained  late  on  the  23rd  contained  albumin ; 
temperature  6  P.M.,  102-6° ;  jaundice  much  more  pronounced. 

2^th  May. — Vomited  black  grumous  fluid  ;  no  urine  passed 
during  the  night ;  bowels  open,  stools  loose,  light  clay  colour. 
Heart  failed  rapidly  and  he  died  at  7  A.M.  There  was  no  con- 
vulsions before  death. 

Case  XII.  —  Mr  R.  D.,  white  man,  agent,  living  in  com- 
mercial town. 

igtk  May. — Was  taken  ill  suddenly.  He  vomited  and  had 
a  high  temperature  1050,  first  seen  on  the  morning  of  20th 
May.  He  then  had  a  temperature  of  1020.  Tongue  furred, 
face  very  flushed,  eyes  injected.  He  took  10  gr.  of  quinine  in 
solution,  and  10  gr.  that  night  when  his  temperature  was  ioo-6°, 
but  without  effect. 

21st  May. — Removed  to  hospital.  On  admission  his 
temperature  was  1010;  pulse  full  and  hard;  skin  moist; 
intense  headache,  otherwise  little  complaint  of  illness ; 
temperature  6  P.M.,  1010.  Was  given  an  intramuscular  in- 
jection of  quinine,  9  gr.,  which  produced  absolutely  no  effect 
on  the  temperature.     No  albumin  in  urine,  which  was  acid. 

22nd May. — Temperature  6  A.M.,  ioi-2°;6  P.M.,  1020.  Seemed 
more  comfortable.  Bowels  open,  motions  normal  in  colour. 
Stated  he  had  passed  a  good  night.  Took  plenty  of  nourish- 
ment. The  jaundice  which  had  been  but  slight  began  to 
become  deeper.  Conjunctivae  very  injected,  and  measles-like 
rash  appeared  on  the  face,  upper  part  of  trunk,  and  back  of 
hands.  Bowels  open  twice,  was  passing  but  little  urine,  only 
12  oz.  in  twelve  hours;  no  albuminuria;  pulse  much  the 
same  as  yesterday.  Liver  was  slightly  enlarged  and  tender, 
but  the  patient  is  very  stout ;  spleen  not  palpable. 

2$rd  May. — Slept  at  intervals  during  the  night.     Tempera- 


190      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

ture  6  A.M.,  102-4° ;  6  P.M.,  102° ;  pulse  not  so  good,  given  brandy 
and  champagne  as  required  ;  jaundice  much  more  pronounced  ; 
conjunctivae  now  deep  saffron  colour.  The  eyes  look  swollen 
and  watery.  Albumin  in  urine ;  more  lethargic ;  not  so  inclined 
to  talk  but  had  tried  to  smoke.  There  was  a  little  nausea  and 
vomiting  at  intervals  during  the  day;  no  "black  specks"  in 
vomit  which  was  of  a  reddish  colour  like  the  dregs  of  beef  tea. 

2^\.th  May. — Temperature  6  A.M.,  1020 ;  6  P.M.,  103-4°.  Had 
passed  a  fair  night.  Bowels  open,  is  not  passing  much  urine ; 
jaundice  very  deep ;  measles-like  rash  fading ;  tongue  fairly 
clean  ;  skin  moist ;  pulse  soft — 70.  Is  taking  nourishment  well 
with  small  quantities  of  stimulant.  There  was  a  little  vomiting 
which  had  changed  its  character,  being  now  marked  with  "  black 
specks  "  more  mucous  than  before  ;  urine  highly  albuminous. 

2^th  May. — Seemed  fairly  well;  temperature  6  A.M.,  ioi°; 
6  P.M.,  ioi°.  Much  more  lethargic  in  the  early  part  of  the  day; 
later  became  restless ;  said  he  could  not  stay  in  bed  ;  kept  on 
getting  up  and  sitting  on  the  side  of  his  bed.  No  complaint  of 
severe  headache,  only  a  dull  ache ;  passing  very  little  urine  in 
the  twenty-four  hours ;  in  consequence  saline  injections  were 
ordered  to  be  repeated  every  four  hours. 

26th  May. — Slept  a  good  deal  last  night ;  continues  to  take 
nourishment  well;  temperature  6  A.M.,  99-4°;  6  P.M.,- 98-8°  ; 
urine  very  albuminous ;  vomiting  not  frequent,  chocolate- 
coloured  ;  pulse  80,  fairly  full  and  soft.  The  pulse  began  to 
fail  a  little  about  midnight.  During  the  greater  part  of  this  day 
he  was  lying  apparently  asleep,  bathed  in  a  profuse  sweat. 
Measles-like  rash  quite  gone,  but  petechias  appeared  for  the  first 
time  about  the  neck  and  trunk,  also  on  the  hands ;  jaundice 
very  deep  ;  hiccough  very  troublesome. 

27th  May. — Some  twitching  about  the  angle  of  the  mouth 
and  hands  first  noticed ;  temperature  98-8°.  Was  semi- 
conscious till  the  afternoon,  when  the  muscular  twitchings 
became  much  more  marked ;  pulse  failing ;  no  urine  since  5  A.M. 
Rectal  saline  injections  were  kept  up.  He  died  quite  quietly 
at  10.45  P-M-  There  was  considerable  haemorrhage  from  the 
mouth  after  death. 

The  post-mortem  examination  was  held  eleven  hours  after 
death.    The  face  and  neck  deeply  cyanosed  ;  petechias  about  the 


GOLD  COAST,  SUSPICIOUS  CASES  191 

upper  part  of  trunk  and  on  the  hands,  rigor  mortis  well  marked  ; 
body  slightly  warm,  the  whole  of  the  abdomen  and  extremities 
of  a  saffron  tint ;  conjunctivae  deep  yellow. 

Heart. — Valves  stained  deep  yellow,  otherwise  normal.  There 
was  early  evidence  of  fatty  degeneration  of  the  muscle  ;  consider- 
able amount  of  fat  on  exterior.  Lungs. — Bases  congested  but 
the  whole  of  both  lungs  crepitant  Stomach  contained  black 
grumous  fluid.  There  was  evidence  of  haemorrhage  from  the 
mucous  membrane  which  was  deeply  congested.  Intestines 
contained  similar  haemorrhagic  matter,  with  marked  congestion 
chiefly  in  the  lower  part  of  small  intestines.  Bladder  appeared 
to  be  healthy  and  contained  about  8  oz.  of  bilious  urine.  Spleen 
slightly  enlarged  and  congested.  Kidneys. — Cortex  thin  with 
haemorrhages  around  base  of  pyramids  and  under  capsule  which 
stripped  readily.  Pancreas. — Beyond  the  deep  staining,  which 
was  a  marked  feature  of  the  whole  of  the  abdominal  viscera,  no 
obvious  change.  Liver. — There  was  slight  enlargement  more 
marked  in  the  left  lobe  than  the  right.  On  section  it  was  of  a 
deep  yellow  colour,  and  had  rather  the  appearance  of  a  "  nut- 
meg." There  were  well-marked  haemorrhages  in  the  tissues, 
covering  the  gall  bladder,  but  not  marked  on  mucous  membrane. 
The  gall  bladder  contained  about  \\  oz.  of  deep  green  gall. 
The  whole  of  the  abdominal  and  thoracic  viscera  appeared  to 
assume  a  deeper  tint  of  yellow  on  exposure  to  the  air.  The 
blood  was  also  of  a  darker  colour  than  normal. 


List  of  Doubtful  Cases  previous  to  the  Outbreak  of  Fatal  Cases ; 
taken  from  the  Secondee  Case  Book. 

J.  C.  E.     Hepatitis.     Date  17/9/04. 

Symptoms — Temperature  1010 ;  pain  in  epigastrium;  coated 
tongue  ;  jaundice  recovered.  W.  S.  W. 

Comment — Suspicious  case  (Boyce). 

T.  B.  W.     Remittent  Fever.     Date  20/9/04. 

Admitted    with    temperature     105-2°;     headache;    tongue 
coated  ;  recovered.  W.  S.  W. 


192      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

F.  G.     Remittent  Fever. 

Admitted  into  Colonial  Hospital ;  temperature  103-6°,  with 
marked  bilious  symptoms  ;  recovered. 

W.  H.  D.     Hepatitis.     Admitted  17/ 11/04. 
Temperature  ioo° ;  usual  symptoms  hepatitis  ;  recovered. 

C.  H.  C.     Insolation  and  Fever.     Date  14/11/04. 
Admitted     with    intense     headache ;      nausea ;     vomiting ; 
temperature    1040.       Very    suspicious    case    of    yellow    fever 
(Boyce). 

J.  B.     Hepatic  Congestion  and  Fever.     Admitted  23/1/05. 

Temperature  104° ;  symptoms — congestion  of  the  liver  and 
other  bilious  symptoms  ;  temperature  ioo°-ioi°,  lasted  ten 
days ;  recovered. 

W.  H.     Date  14/2/05. 

Symptoms  of  intermittent  fever  and  gastric  catarrh,  with 
marked  gastric  disturbance  ;  eight  days'  duration  ;  recovered. 

A.  T.  N.,  District  Commissioner,  set.  twenty-eight.     Admitted 

23/2/05. 

Diagnosis — Remittent  fever  germinated  fatally. 

G.  F.  S.     Diagnosis — Remittent  Fever.     Admitted  26/2/95. 

Temperature  1030 ;  vomiting ;  fever  characterised  by  gastric 
and  bilious  symptoms ;  recovered  in  ten  days. 

F.  G.  M.     Diagnosis — Enteritis. 
Temperature  103-4°  5  vomiting  six  days. 

H.  H.  H.     Intermittent  Fever;  recovered.     Date  21/3/05. 
Temperature  103° ;  nausea  ;   vomiting  and  gastric  disturb- 
ance ;  recovery  ;  quinine  did  not  affect  the  temperature. 

G.  F.  S.     Gastric  Catarrh  and  Fever.     Date  17/3/05. 
Admitted   suffering   from   vomiting;    continuous  fever  and 
prostration ;  invalided. 


GOLD  COAST,  SUSPICIOUS  CASES  193 

T.  H.  F.     Hsemoglobinuric  Fever  ;  recovered.    Admitted 

14/5/05. 

Temperature  1030 ;  weakness ;  urine  and  alb.  looks  like 
that  of  blackwater ;  skin  very  yellow ;  much  bilious  vomit- 
ing ;  temperature  1040 ;  vomiting  continued  ;  recovery. 

H.  C.  R.,  Mines  Accountant.     Blackwater  Fever.     Date 

8/6/05. 

Admitted  to  hospital  with  well-marked  symptoms  of  black- 
water  ;  urine  alb. ;  skin  yellow ;  vomiting  same  afternoon ; 
temperature  104-2°;  recovery. 

H.  H.     Intermittent  Fever. 

Admitted  vomiting  and  great  irritability  of  stomach ; 
recovery. 

E.  D.  M'F.     Bilious  Remittent  Fever.     Admitted  26/8/05. 

Temperature  102-6°;  jaundiced;  headache;  nausea;  tem- 
perature rose  to  104-6°. 

A.  W.  H.     Diagnosis  not  given.     Death.     Admitted  5/1/07. 

6th January  1907. — Vomiting  commenced;  black  vomit  on 
the  7th ;  eyes  intensely  congested  and  jaundiced  ;  skin  yellow, 
with  purple  patches  of  discoloration ;  temperature  103°  ; 
delirium  ;  coma  ;  epistaxis. 

Post-mortem. — Skin  yellow  ;  conjunctivae  yellow  ;  lungs  con- 
gested ;  liver  fatty ;  kidneys  congested ;  trace  alb.  in  urine ; 
intestines  contained  same  material  as  the  vomit.  Undoubted 
case  of  yellow  fever;  temperature  102°,  with  a  pulse  of  96 
(Boyce). 

Mr  K.     Dysentery  and  Blackwater  Fever.     Admitted  1 3/1/04. 

Symptoms.  —  Vomiting;  epistaxis;  blood  in  stool;  black- 
water  ;  skin  jaundiced  ;  pulse  96  ;  epistaxis  ;  recovery. 

John  (Convict  Prisoner).     Cirrhosis  of  Liver.     Date  26/4/07. 

Symptoms. — Jaundice ;  bleeding  from  gums  ;  eyes  irritating  ; 
coma ;  death. 

N 


194      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

C.  L.     Blackwater  Fever.     Date  26/9/98. 

Admitted  with  severe  rigors ;  vomiting  and  incessant 
hiccough  with  blackwater  ;  death. 

A.  M.  D.,  Senior  Nursing  Sister.      Blackwater  Fever.     Date 

18/6/08. 

Arrived  10th  May  1908;  attack  of  fever;  severe  vomiting; 
haemoglobinuria  in  urine ;  recovery. 

H.  L.     Hepatitis,  Asthenia.     Admitted  2/2/10. 

Had  suffered  from  malaria  on  admission ;  vomiting  large 
quantities  of  bilious  matter;  abdomen  tender;  temperature  rose 
to  1030;  death. 

R.  C.     Admitted  19/3/ 10. 

Arrived  in  Secondee,  Thursday,  10th  March,  from  Accra; 
complains  of  vomiting;  headache;  temperature  ioi-6°;  no 
albumin. 

21  st  March. — Temperature  1030 ;  nausea. 

23rd  March. — Temperature  102° ;  nausea;  vomiting;  skin 
yellow;  later  temperature  1050. 

Note. — The  patient  lived  in  the  same  compound  where  Mr 
Aisly  resided.     Dr  Ralph  regarded  the  case  as  one  of  typhoid. 

Outbreak  of  Yellow  Fever  at  Saw  Mills,  19 10. 

A  case  of  yellow  fever  was  reported  at  Saw  Mills  Camp,  a 
station  12 \  miles  along  the  railway,  north  of  Secondee.  This 
camp  consisted  of  a  small  village  of  about  thirty-five  houses 
occupied  by  natives,  and  of  two  European  bungalows  occupied 
by  the  white  men. 

The  village  was  very  dirty,  and  littered  with  innumerable 
odds  and  ends  which  contained  water,  and  gave  rise  to  enormous 
numbers  of  mosquitos.  The  outbreak  at  this  small  isolated 
camp  is  of  great  interest,  as  it  shows  in  a  most  conclusive 
manner  the  independent  occurrence  of  a  sporadic  case  \2\  miles 
from  the  focus  at  Secondee.  According  to  the  history  of  the 
case,  the  patient  had  not  been  near  Secondee  for  three  weeks 


CASE  AT  AXIM,  1910  195 

previous  to  taking  ill.  It  would  therefore  appear  that  this 
case  originated  in  Saw  Mills,  precisely  as  the  case  in  Secondee, 
from  Stegomyia,  which  had  become  infected  from  the  disease 
present  in  an  unrecognised  form  in  the  natives.  In  other 
words,  the  case  is  further  evidence  of  the  endemic  origin  of 
yellow  fever  in  West  Africa. 

Symptoms  of  the  case. — Mr  P.  M.,  aet.  forty-six. 

15//2  June.  —  Reported  to  have  taken  suddenly  ill,  with 
headache  and  temperature  of  1050. 

i6tk  June. — Conditions  the  same,  with  bilious  vomiting  and 
hiccough  and  sleeplessness. 

\Jth  June. — Conditions  unaltered  :  temperature  1050. 

i8tn  June. — Was  brought  down  to  the  hospital  at  Secondee. 
He  developed  black  vomit ;  great  weakness ;  temperature  980  ■ 
pulse  60 ;  hiccough  and  vomiting  became  persistent ;  jaundice 
set  in  skin  and  conjunctivae.  During  the  night  the  temperature 
was  990,  and  pulse  very  slow,  56;  vomiting  incessant.  The 
quantity  of  urine  passed  was  small,  and  contained  albumin. 

19th  June. — Patient  delirious;  black  vomiting  continued  up 
till  death. 

This  is  a  very  clear  case  of  severe  yellow  fever,  show- 
ing jaundice,  Faget's  sign,  albuminuria,  and  intense  black 
vomiting.  There  was  only  one  paroxysm  of  fever,  and  no 
relapses. 

Occurrence  of  a  Sporadic  Case  of  Yellow  Fever  at  Axim,  19 10. 

As  in  the  case  of  Saw  Mills,  so  in  this  one  at  Axim,  there 
occurs  an  independent  sporadic  case,  the  infection  in  which 
case  cannot  be  traced  to  the  outbreak  at  Secondee.  We  there- 
fore are  obliged  to  conclude  that,  as  in  Secondee  and  in 
Saw  Mills,  the  disease  originated  on  the  spot — in  other  words, 
that  yellow  fever  is  endemic  and  exists  amongst  the  natives. 
This  opinion  is  that  adopted  by  the  Senior  Sanitary  Officer, 
Dr  Rice,  who  observed  on  the  spot  the  whole  outbreak  this 
year,  19 10. 


196      THE  SYMPTOMS  OF  SOME  OF  THE  CASES 

Symptoms. — Mr  G.  R.,  newly  arrived  from  England.1 

\2tk  July. — Taken  ill  with  headache,  and  temperature  1040 ; 
pulse  85;  no  albuminuria;  no  jaundice  or  vomiting;  was 
given  quinine. 

i^th  July. — Temperature  104-2°;  pulse  87. 

14.1/1  July.  —  Temperature  ioi-8°;  pulse  j6\  patient 
appeared  much  better  and  more  cheerful.  At  8  p.m.,  however, 
the  doctor  was  suddenly  summoned,  and  found  the  patient 
delirious;  very  weak;  temperature  101-2°  ;  vomited;  first  vomit 
greenish,  the  others  were  white. 

i$tk  July. — Patient  delirious  and  raving;  reported  not  to 
have  passed  water  since  the  13th  ;  died. 

Post-mortem  examination  showed  the  liver  enlarged  and 
yellowish ;  jaundice  well  marked  (it  had  not  appeared  before 
death).  The  bladder  was  empty ;  the  stomach  was  not  injected  ; 
the  spleen  was  not  enlarged  ;  the  kidneys  enlarged. 

Although  the  notes  of  the  case  are  scanty,  the  case  appears 
to  me  to  be  a  clear  one  of  yellow  fever.  It  is  a  fever  of  one 
paroxysm,  lasting  four  days,  and  terminating  fatally ;  the  pulse 
was  comparatively  slow,  gastric  symptoms  appeared  on  the 
second  or  third  day.  It  is  true  that  there  was  no  black  vomit, 
but  there  was  the  white  vomit  which  has  been  often  recorded. 
Nor  did  jaundice  appear  till  after  death :  this  is  also  very 
common.  Then  there  is  the  suppression  of  urine.  The  liver 
is  found  to  be  yellowish.  In  my  opinion,  the  symptoms  and 
findings  can  only  point  to  yellow  fever. 

1  Mr  G.  R.  was  a  fellow-passenger  with  me  on  my  way  out  to  the  Coast 
(Boyce). 


CHAPTER  XI 

DIAGNOSIS 

Difficulties  of  diagnosis  met  with  during  epidemics. —  Although 
a  "  well-marked "  case  of  yellow  fever  cannot  readily  be 
mistaken  for  any  other  disease,  it  unfortunately  happens  that 
at  the  commencement  of  an  outbreak  the  "well-marked"  cases 
are  rare,  whilst  the  milder  types  to  which  I  have  already 
fully  alluded,  predominate.  Therefore  it  becomes  a  matter  of 
supreme  importance  to  review  the  histories  of  past  outbreaks, 
and  to  learn  from  them  the  practical  difficulties  which  medical 
men  have  had  to  contend  with,  in  arriving  at  the  true  nature  of 
the  disease  which  had  broken  out  in  their  midst.  After  a 
searching  examination  of  the  outbreak  of  yellow  fever  in  British 
Honduras  in  1905,  I  wrote  in  my  report  to  the  Government 
as  follows,  upon  the  question  of  mistakes  in  diagnosis  : — 

"  1.  Malaria} — In  January  1905,  two  deaths  occurred  from 
remittent  malaria  in  subjects  aged  twenty-two  and  forty-five 
respectively,  and  one  death  from  intermittent  malaria  in  a 
baby  of  one  and  a  half  months  ;  in  February  one  remittent 
case  in  a  man  of  thirty-seven ;  in  March  one  remittent  case 
in  a  woman  of  thirty-two,  and  in  April  two  remittent  cases,  one 
in  a  man  of  seventy,  the  other  in  a  man  of  thirty.  On 
14th  May,  the  death  occurred  of  Miss  B.,  from  what  was 
registered  at  the  time  as  bilious  fever  and  hoematemesis,  but 

1  The  term  "malaria"  has  become  in  the  tropics  a  kind  of  medical  dust-bin, 
into  which  all  difficult  or  doubtful  cases  of  fever  are  cast  without  question 
or  microscopical  analysis.     It  takes  the  place  of  syphilis  in  colder  climates. 

197 


198  DIAGNOSIS 

which  there  is  now  no  doubt  was  yellow  fever.  Later,  in  May, 
and  in  June,  July,  and  August,  further  deaths  occurred  from 
what  was  chiefly  described  as  malignant  malaria  or  remittent 
malaria ;  some  of  these,  there  is  now  reason  to  believe,  as  will 
be  shown  further  on,  were  caused  by  yellow  fever. 

"  In  the  practice  of  the  local  medical  men  there  were,  of 
course,  numerous  cases  of  malaria  as  in  other  years ;  there 
appears  to  me,  however,  to  be  no  doubt  that  in  January,  May,  and 
April  the  number  of  'fever'  cases  were  abnormally  high.  I 
am  also  informed  by  Dr  White,  of  the  Public  Health  and  Marine 
Hospital  Service  of  the  United  States,  who  had  charge  of  the 
yellow  fever  prophylactic  measures  in  New  Orleans,  that  the 
same  marked  increase  of  what  was  returned  as  'malaria'  was 
noted  previous  to  the  official  declaration  of  yellow  fever.  It  is 
most  probable  that  some  of  these  cases  were  yellow  fever. 

"  With  regard  to  the  symptoms  which  the  cases  of  malaria 
presented  in  Belize,  I  have  been  furnished  with  the  following 
details.  Many  were  cases  of  persistent  fever,  lasting  from  ten 
to  twenty  days,  refractory  to  treatment ;  quinine  witJwut 
effect;  fever  intermittent;  temperature  ioo°  -  1030 ;  pulse 
slow,  60-80  ;  urine  high-coloured  and  containing  bile  ;  bowels 
constipated.  Or  again,  '  the  majority  of  cases  dating  from  the 
end  of  1904  and  commencement  of  1905  were  complicated  with 
jaundiced  scleras,  occasional  slow  pulse  and  high  temperature. 
The  discoloration  of  the  scleras  was  slight,  however,  and  passed 
off  in  a  day  or  two.'  In  the  severer  forms  '  bilious  vomiting  was 
recorded.'  From  what  I  have  myself  observed  this  year,  and 
from  the  description  of  cases  in  former  years  where  disputes 
have  arisen  over  mistaken  diagnosis,  I  am  of  opinion  that  it  is 
often  very  difficult  to  distinguish  between  yellow  fever  and 
certain  types  of  malaria,  in  which  there  may  be  present  a  very 
slow  pulse ;  jaundice ;  vomiting ;  bleeding  from  the  gums ; 
delirium  ;  retention  of  urine  ;  traces  of  albumin  ;  constipation  ; 
and  where  quinine  does  not  have  any  marked  effect.  In 
autopsies  upon  these  cases  I  have  noted  in  one  instance  intense 


INFLUENZA  AND  MILD  CASES  199 

congestion  of  the  gastric  mucous  membrane,  precisely  as  in 
yellow  fever.  Nor  does  the  finding  of  the  malarial  parasites 
in  the  blood  by  any  means  settle  the  diagnosis  in  districts  in 
which  malaria  is  common  ;  instances  were  recorded  this  summer 
in  New  Orleans,  in  which  obvious  cases  of  yellow  fever  presented 
the  malarial  parasites  in  the  blood,  and  we  know  that  malaria 
does  not  protect  from  yellow  fever.  Unquestionably,  the  post- 
mortem is  the  most  reliable  method  of  arriving  at  a  correct 
diagnosis,  and  no  stone  should  be  left  unturned  to  obtain  an 
autopsy  in  any  suspicious  case.  It  is  also  very  clear  that  in 
countries  liable  to  yellow  fever  a  close  watch  must  be  kept 
upon  a  rise  in  the  mortality  from  '  malaria,' especially  in  months 
when  such  a  rise  is  unusual. 

"  2.  The  influenza  cases. — Commencing  towards  the  end  of 
April  and  lasting  to  the  middle  of  May,  there  was  a  short  three 
weeks'  epidemic  of  a  disease  which  was  recorded  as  influenza, 
and  which  presented  the  following  symptoms : — The  onset  of 
the  disease  was  sharp,  but  did  not  last  long,  the  patient  going 
to  work  on  the  fourth  or  fifth  day.  All  the  members  of  a 
family  might  be  attacked,  one  after  the  other,  and  both  fresh 
arrivals  and  old  residents  were  equally  affected,  as  also  the 
white  and  black  population.  There  were  no  fatal  cases.  The 
symptoms  consisted  of  a  severe  headache;  temperature  1040- 
1050 ;  rapid  and  extreme  prostration  ;  vomiting  not  as  a  rule 
present." 

During  my  investigations  last  year,  1909,  upon  the  out- 
break of  yellow  fever  in  Barbados,  I  noted  that  yellow  fever 
had  been  repeatedly  mistaken  for  other  diseases.  The  following 
extract  is  an  example  of  many  similar  ones. 

1.  Mild  cases. — Extracts  from  the  Quarterly  Sanitary 
Report  of  the  parochial  medical  officer  re  yellow  fever  in 
Barbados : — 

"Dr  T.  S.  B.,  No.  1  District,  St  Michael,  31st  March  1908. 
During  this  quarter  I  have  attended  29  cases  of  fever,  lasting  as 


200  DIAGNOSIS 

a  rule  from  three  to  five  days  :  one  case  of  yellow  fever  occurred 
in  my  district  on  which  a  post-mortem  was  made,  and  it  was 
duly  notified.  Several  of  these  cases  presented  some  symptoms 
of  yellow  fever,  and  I  recognised  them  as  those  which  in  the 
epidemic  of  yellow  fever  in  1881  were  called  '  febricula,'  and 
were  then  considered  by  the  medical  men  who  saw  that 
epidemic  as  very  mild  cases  of  yellow  fever,  as  the  initial 
symptoms  were  the  same  as  those  in  which  yellow  fever  after- 
wards developed.  Some  medical  men  have  considered  these 
cases  to  be  '  gastric  influenza,'  but  as  no  severe  type  of  influenza 
was  present  while  these  cases  occurred,  I  fail  to  see  how  '  gastric 
influenza '  can  be  associated  with  these  cases.  Further,  if  they 
were  of  the  nature  of  influenza,  we  would  have  had  thousands 
of  these  cases  instead  of  the  few  cases  that  did  occur,  as  the 
swiftly  spreading  and  sudden  invasion  of  influenza  is  well 
known.  It  should  be  noted  that  when  cases  of  gastric  influenza 
recently  occurred  in  England,  there  was  at  the  same  time  an 
epidemic  of  influenza  of  the  ordinary  kind,  which  affected  the 
nasal  and  respiratory  parts  with  which  influenza  is  generally 
associated." 

The  following  very  interesting  account  of  gastric  influenza 
has  been  kindly  furnished  me  by  a  consulting  physician  residing 
in  Barbados  : — 

2.  "  Gastric  influenza. — The  term  '  gastric  influenza '  has 
been  applied  by  some  medical  men  in  Barbados  during  the  last 
year,  to  cases  which  other  medical  men  regarded  and  notified 
as  genuine  yellow  fever. 

"  I  say  this  without  hesitation,  because  one  man  saw  two 
cases  and  another  man  one  case  in  consultation  with  me,  which 
were  all  regarded  by  two  other  men  and  myself  as  undoubted 
yellow  fever.  These  were  all  fatal  in  from  three  to  five  days  in 
white  persons  with  early  albuminuria,  lemon-coloured  urine ; 
suppression  of  urine  ;  black  vomit;  and  yellow  discoloration  of 
the  body ;  slight  during  life,  and  pronounced  after  death.  One 
of  these  cases  was  verified  by  a  post-mortem  examination, 
which  revealed  a  typical  '  boxwood '  liver ;  stomach  showing 
arborescent  congestion  and  containing  black  fluid.  Other  fatal 
cases  characterised  by  '  black  vomit '  were  heard  of  from  time  to 


EPIDEMIC  JAUNDICE  AND  MALARIA  201 

time,  which  were  not  notified,  and  which  were  commonly  spoken 
of  as  'gastric  influenza.'  " 

3.  Epidemic  jaundice  or  Weil's  disease. — This  disease  was 
likewise  frequently  diagnosed  in  cases  of  yellow  fever.  There 
are  points  of  resemblance,  notably  sudden  onset ;  lumbar 
pain  ;  vomiting ;  high  temperature  and  slow  pulse  ;  jaundice. 
There  is  not,  however,  the  black  vomit  or  albuminuria. 

4.  Dengue  fever  gave  rise  to  much  difficulty  of  diagnosis, 
and  very  many  cases  of  yellow  fever  were  returned  under  it. 

As  the  result  of  my  investigations  in  West  Africa  this  year, 
1 9 10,  it  is  abundantly  evident  that  a  very  considerable  amount 
of  mistaken  diagnosis  has  taken  place  in  past  years,  more 
in  West  Africa,  perhaps,  than  in  any  other  country  with  which  I 
am  acquainted ;  for  the  reason,  no  doubt,  that  very  little  pro- 
minence has  hitherto  been  given  to  this  disease,  as  a  disease 
likely  to  be  encountered  any  day.  Much  has,  we  know,  been 
written  upon  the  existence  of  yellow  fever  in  West  Africa,  but 
this  has  lain  buried  in  old  medical  books  or  naval  and  military 
returns,  which  were  never  consulted.  Further,  with  the  increased 
attention  given  to  malaria,  I  am  afraid  that  it  was  too  often 
taken  for  granted  that  coast  fevers  must  all  be  due  to  the  malarial 
parasites,  without  even  making  a  careful  blood  examination. 
Both  French  and  German  writers  upon  yellow  fever  in  West 
Africa  have  noted  that  this  disease  has  been  mistaken 
for  other  diseases,  notably  bilious  remittent  fever  and  pernicious 
forms  of  malaria,  "  bilious  remittent  fever  with  morbus  cordis," 
febris  malarice  continua  perniciosa  nephritica,  etc.  Examination 
of  the  hospital  case  books  in  towns  on  the  Gold  Coast  in  Lagos 
and  at  Freetown  this  year,  1910,  showed  numerous  instances  of 
mistaken  diagnosis.  The  following  are  a  few  typical  examples 
arranged  under  the  heads  of  malaria,  remittent  fever,  etc. : — 

I.  Malaria 

There  is  no  doubt  that  genuine  cases  of  yellow  fever  have 
been   diagnosed    as   simple    malaria,    pernicious    or    malignant 


202  DIAGNOSIS 

malaria,  blackwater,   etc.     Moreover,  this   diagnosis   has   been 
made  without  a  careful  blood  examination. 

Examples  of  Cases  diagnosed  as  "  Malaria" 

Symptoms  of  a  case  at  Elmina  in  1905  : — iSt/i  April. — 
Temperature  102-4°  5  pulse  100 ;  intense  head  and  backache  ; 
nausea ;  epigastric  pain. 

igt/i  April. — Temperature  103-4° ;  pulse  92. 

2.2nd  April.  —  Black  vomit  appeared,  then  death.  Post- 
mortem examination  showed  skin  yellow ;  liver  and  kidneys 
congested ;  black  vomit  in  the  stomach.  Dr  W.  M.  Elliott 
considered  this  to  be  a  case  of  yellow  fever,  as  also  a  case 
diagnosed  in  March  previously  as  "  hepatic  fever." 

In  1902  at  Cape  Coast  .  the  following  fatal  case  of 
"  malaria  "  : — 

Patient  admitted  with  temperature  102° ;  pulse  very  slow 
in  comparison  with  the  temperature ;  later  temperature,  108-2° ; 
vomiting  persistent ;  first  brown  then  black ;  black  motion ; 
marked  albuminuria ;  liver  yellow ;  stomach,  intestines,  and 
kidneys  deeply  congested.  In  this  year  a  severe  case  of  yellow 
fever  was  also  diagnosed,  so  that  it  is  obvious  this  is  also  a  case. 

Malignant  malarial  fever. — Symptoms  of  a  case  at  Elmina, 
1906: — 

History  of  persistent  vomiting,  ending  with  coffee-ground 
vomit;  jaundiced  skin;  temperature  103-6°  and  pulse  100;  fatal 
termination.  No  reason  is  ascribed  for  making  the  diagnosis 
malignant  malaria :  it  is  probably  one  of  the  numerous  cases  of 
assumption. 

Case  at  Saltpond,  1898.     Symptoms: — 

Temperature  105-4°  and  rose  to  107-2° ;  violent  delirium  ; 
skin  jaundiced ;  also  cutaneous  haemorrhages  over  head  and 
shoulders ;  coma  and  death.  At  the  post-mortem  stomach- 
wall  intensely  congested,  and  contains  dark  green  treacly 
material ;  intestines  congested ;  liver  peculiar  saffron  colour 
with  patches  of  congestion.  It  is  stated  that  a  blood  examina- 
tion showed  this  presence  of  pigmented  corpuscles.  Considering, 
however,  that  in  the  previous  year  1 897  there  had  been  several 
cases  of  yellow  fever,  I  am  of  opinion  that  this  is  also  one  of  that 
disease. 


BLACKWATER  FEVER  203 

In  1902  the  following  fatal  case  was  diagnosed  as  malarial 
at  Cape  Coast : — 

Temperature  1030 ;  pulse  80,  slow  in  comparison  to  the  tem- 
perature; later  pulse  74;  vomiting  and  retching  ;  delirium;  later 
black  vomit  and  black  motion ;  haemorrhages  from  the  mouth. 

Post-mortem. — Skin  yellow ;  stomach  congested ;  there  was 
no  blackwater. 

Blackwater  fever,  as  is  well  known,  resembles  in  some 
respects  yellow  fever.  The  essential  points  to  bear  in  mind  are 
that  in  blackwater  there  is  a  history  of  undoubted  previous 
attacks  of  malaria  and  exposure  to  malarial  infection  ;  secondly, 
that  the  disease  is  a  haemoglobinaemia,  and  that  the  "  black  "  colour 
of  the  urine  is  due  to  the  excreted  haemoglobin  present  in  the  blood 
serum.  There  is  of  course  also  albuminuria,  but  red  corpuscles, 
cell  and  hyaline  casts  are  usually  present  in  yellow  fever.  The 
red  colour  of  the  urine,  when  present  in  yellow  fever,  is  due  to 
red  corpuscles,  and  casts  are  very  often  present.  Therefore  there 
is  an  essential  difference  in  the  urine  in  the  two  cases.  More- 
over, the  hemoglobinuria  is  observed  at  the  commencement  of 
the  illness  in  blackwater,  and  there  is  a  history  that  it  has  come 
on  suddenly  or  has  been  brought  on  by  quinine  or  other  factors. 
In  blackwater  the  urine  is  diminished  owing,  it  is  thought, 
to  the  blocking  of  the  collecting  tubes  in  the  kidney.  In 
yellow  fever  there  is  also  frequently  suppression  ;  the  kidneys,  in 
other  words,  are  profoundly  affected.  In  both  diseases  there  is 
jaundice,  but  the  jaundice  of  yellow  fever  develops  during  the 
progress  of  the  disease,  and  often  does  not  appear  until  the 
death  agony.  There  is  vomiting  in  both  diseases,  but  the 
character  of  the  vomit  and  the  pumping  action  of  the  stomach 
is  characteristic  in  yellow  fever.  As  the  mechanism  of  the 
jaundice  in  yellow  fever  and  blackwater  differs  essentially,  one 
does  not  find  Faget's  symptom  in  blackwater  fever.  There- 
fore taken  altogether  there  ought  to  be  no  difficulty  in 
differentiating  the  two  diseases. 

Closely    following    upon    malaria    comes    the    exceedingly 


204  DIAGNOSIS 

numerous  cases  of  remittent,  bilious  remittent,  and  pernicious 
remittent  fevers,  which  are  often  other  names  for  yellow  fever.  It 
is  admitted  that  these  names  convey  very  little  precise  informa- 
tion as  to  what  they  really  are.  In  most  cases  they  are  supposed 
to  be  forms  of  malaria,  but  why,  in  the  absence  of  all  blood  para- 
sites they  should  be  so  considered,  is  very  difficult  to  understand. 
The  more  I  examine  this  group,  the  more  I  am  convinced  that 
in  a  large  number  of  cases  the  fever  is  due  to  Stegomyia  infection. 
The  following  are  some  good  examples  out  of  innumerable 
cases : — 

II.  Remittent  Fever. 

Symptoms  of  a  case  at  Axim,  1906  : — 

\oth  May. — Patient  taken  ill,  feeling  "sick  and  bilious"; 
temperature  1050 ;  took  25  gr.  of  quinine. 

nth  May. — Temperature  1040 ;  pulse  120. 

12th  May. — Temperature  1040;  pulse  1 10-120;  taking 
quinine  in  large  doses. 

13th  May. — Temperature  1030;  the  quinine  did  not  appear 
to  have  any  effect  whatever.     Patient  wandering. 

14th  May. — Temperature  1010;  rigor;  skin  becomes  cold 
and  patient  unconscious. 

This  is  a  one-paroxysm  fever  ending  fatally  on  the  fifth  day, 
in  which  quinine  had  no  effect.    It  is  suspicious  of  yellow  fever. 

Symptoms  of  a  case  at  Elmina,  1895  : — 

On  admission,  temperature  103-4°;  pulse  124;  headache; 
vomiting ;  epigastric  tenderness.  On  the  following  day 
temperature  101-4°;  pulse  90.  On  the  third  day,  temperature 
102° ;  pulse  80 ;  delirium.  This  is  a  suspicious  case,  especially 
in  view  of  the  fact  that  yellow  fever  appeared  later  in  its  severe 
type.  There  were  many  more  cases  of  remittent  fever  during 
1895  and  subsequently,  in  some  of  which  the  symptoms  were 
very  suspicious,  notably  the  pulse  rate  not  following  the  run  of 
temperature.  There  is,  moreover,  no  doubt  that  Dr  Elliott,  who 
was  present,  had  his  suspicions  aroused. 

Case  at  Saltfiond,  1895.     Symptoms  : — 

22nd  March. — Patient  unwell ;  temperature  1 03° ;  pulse  100; 
headache  and  vomiting. 


REMITTENT  FEVER  205 

2$rd  March. — Vomiting  increased;  suppression  of  urine  for 
two  days. 

24th  March. — Temperature  99-8° ;  pulse  80 ;  vomiting  and 
hiccough. 

2$th  March.  —  Temperature  1030;  delirious;  jaundice 
noticed ;  vomited  coffee-ground  material. 

26^/2  March. — Temperature  105-8° ;  pulse  60  ;  yellow  colour 
skin  much  deeper. 

2%th  March. — Vomited  brown  material  and  a  cupful  of 
blood  ;  then  coma  and  death.  After  death  the  jaundice  colour 
was  much  more  pronounced.  There  can  be  no  doubt  this  is  a 
typical  case  of  severe  yellow  fever. 

Case  at  Accra,  1904  : — 

Case  I. — Patient  had  been  short  time  in  the  Colony  and 
was  adverse  to  mosquito  nets. 

igth  April. — Taken  ill. 

2\st  April. — Temperature  104°;  pains  over  body. 

2^rd  to  2\th  April. — Vomited  black  coffee-ground  material 
and  passed  tarry  stools. 

2$th  April. — Vomiting  persistent  and  violent;  hiccough; 
delirium  ;  coma  ;  death. 

Case  II.,  1905. — Symptoms — intense  headache  ;  temperature 
101-8°,  later  104°;  albuminuria;  quinine  without  effect;  vomit- 
ing persistent ;  became  drowsy  and  less  urine  passed.  Patient 
was  taken  ill  on  the  19th  July  and  died  on  the  24th. 

The  first  case  is,  in  my  opinion,  yellow  fever,  and  the  second 
case  is  very  suspicious. 

Cases  at  Cape  Coast. — In  the  year  1901  there  were  entered 
seven  cases  of  remittent  fever  and  two  cases  of  bilious  remittent 
fever ;  of  these  eight  proved  fatal.  When  it  is  remembered  that 
the  following  year,  1902,  yellow  fever  was  diagnosed,  it  is  most 
probable  that  the  majority  of  the  previous  cases,  fatal  cases, 
were  also  that  disease.  In  1895,  at  Cape  Coast,  two  fatal  cases 
of  yellow  fever  occurred  and  several  cases  of  fatal  remittent  fever. 

Case  I. — Symptoms — great  weakness  ;  jaundice ;  tempera- 
ture 101°  to  105°;  anorexia;  epigastric  tenderness;  delirium; 
patient  passed  a  black  motion ;  later  felt  better ;  followed  by 
relapse  and  death. 


206  DIAGNOSIS 

Case  II. — Taken  ill  28th  May  with  nausea;  vomiting  and 
pain  in  back,  ^rd  June. — Felt  better  and  breakfasted.  4th  June. 
— Much  worse;  temperature  1030;  persistent  vomiting  ;  intense 
lumbar  pain.  7th  June. — Patient  became  jaundiced  and  died. 
This  patient  had  arrived  on  the  Coast  on  15th  May — that  is, 
thirteen  days  previous  to  his  illness. 

In  1901  at  Cape  Coast  there  are  a  series  of  fatal  cases  of 
remittent  fever  and  some  cases  of  bilious  remittent ;  as  these 
were  followed  by  severe  yellow  fever  cases  in  the  following  year, 
there  can  be  little  doubt  that  some  of  these  were  genuine  yellow 
fever  cases. 

In  1902  at  Cape  Coast  there  were  also  fatal  cases  of 
remittent  fever,  followed  by  typical  cases  of  yellow  fever. 

Case  oj  Pernicious  Remittent  Fever  at  Axim,  19 10  : — 
There  was  sudden  onset ;  temperature  1030 ;  severe  head- 
ache ;  pulse  88 ;  temperature  rose  to  1040 ;  the  intramuscular 
injection  of  quinine  was  without  effect ;  delirium  developed ; 
then  coma  and  death.  In  my  opinion,  and  in  view  of  subsequent 
development,  this  was  a  case  of  yellow  fever. 

Cases  of  bilious  remittent  fever  in  Saltpond,  1898. 
Symptoms : — 

Case  I. — Sudden  onset ;  headache ;  vomiting ;  temperature 
103-2°;  skin  tinged  yellow;  conjunctivae  congested  and  yellow; 
pulse  90;  delirious;  later  temperature  104°;  pulse  weak,  and 
death. 

Case  II. — Vomiting;  temperature  102°;  convulsions,  and 
death. 

Case  III. — Temperature  102-5°;  slight  jaundice ;  pain  in 
head  and  back  ;  recovery. 

Case  IV. — A  similar  case. 

These  cases  are  in  all  probability  yellow  fever.  They  were 
preceded  and  followed  by  genuine  cases  of  yellow  fever. 

Cases  at  Cape  Coast. — Severe  cases  of  this  disease  were 
entered  in  1901  and  1904,  which  were  preceded  or  followed  by 
yellow  fever  cases.     See  also  case  at  Secondee,  1910. 

After  the  remittent  fevers  there  comes  a  list  of  rarer 
mistaken    diagnoses  —  for    example :     Subacute    rheumatism, 


YELLOW  FEVER  IN  CHILDREN  207 

lumbago,  gastric  ulcer  and  gastritis,  hepatitis,  acute  yellow 
atrophy,  etc. 

The  following  is  a  case  diagnosed  as  hepatitis,  which  in  all 
probability  was  yellow  fever : — Symptoms  of  a  case  at  Elmina, 
1895. — Admitted  with  great  prostration;  skin  yellow;  eyes 
jaundiced ;  black  coffee-ground  vomit ;  suppression  of  urine  ; 
and  death.  Dr  W.  M.  Elliott  regarded  this  as  very  suspicious 
of  yellow  fever. 

Looking  over  hospital  case  books  shows  that  time  and  time 
again  the  medical  officers  have  been  greatly  perplexed  as  to 
what  should  be  their  diagnosis  in  certain  cases.  They  often 
shunned  the  notoriety  of  the  more  startling  diagnosis  of  yellow 
fever,  and  tried  to  satisfy  their  conscience  by  a  diagnosis  such  as 
the  following,  which  is  one  of  many  similar  ones  : — 

"  Resembling  yellow  fever." — Case  at  Elmina,  1902. — In  this 
case  there  was  intense  headache  ;  albuminuria  ;  jaundice  ;  black 
vomit  and  black  motion ;  and  intense  yellow  colour  of  skin 
before  death.     This  was  most  probably  a  case  of  yellow  fever. 

III.  Dengue  or  Dandy  Fever 

At  present  the  differential  diagnosis  between  yellow  fever 
and  dandy  fever  in  West  Africa  is  not  of  great  practical 
importance,  but  probably  in  the  future  with  the  growth  of 
sewage  schemes  and  the  increased  facilities  given  to  breeding 
culex,  the  disease  will  become  as  prominent  as  in  the  West 
Indies  and  other  parts  of  the  world. 

IV.  Yellow  Fever  in  Children 

Yellow  fever  occurs  in  children  in  forms  which  do  not 
suggest  yellow  fever,  and  there  is  little  doubt  that  the  disease 
in  them  passes  unrecognised  ;  this  was  certainly  the  case,  in  my 
opinion,  in  the  Belize  outbreak  in  1905.  Sodre  &  Couto  sum 
up  the  case  thus  : — "  During  an  epidemic  of  yellow  fever,  if  a 
child  is  affected  by  a  fever  lasting  more  than  twenty-four  hours 
and  followed  by  symptoms  of  nervous  irritation,  the  diagnosis 
in  95  per  cent,  of  the  cases  will  be  yellow  fever."  Durham  also 
draws  attention  to  the  part  played  by  children  in  propagating 
yellow  fever  just  as  they  do  malaria,  scarlet  fever,  etc. 


CHAPTER    XII 

TREATMENT 

There  is  no  specific  drug  which  is  of  any  use.  Nevertheless,  by 
the  careful  consideration  of  the  pathology  of  the  disease,  and  of 
the  probable  mode  of  action  of  the  virus,  and  bearing  in  mind 
the  treatment  of  the  experimental  inoculation  cases  of  Reed, 
Carroll,  Agramonte,  and  Lazear,  it  is  possible  to  adopt  a  system 
of  treatment  which,  although  exceedingly  simple,  nevertheless 
attains  to  an  almost  specific  position.  Summed  up,  the 
treatment  resolves  itself  into  absolute  rest  of  body,  alimentary 
tract,  and  abdominal  viscera.  Allow  the  patient  to  do 
nothing  that  will  cause  effort  of  any  kind.  In  other  words, 
remembering  that  the  patient  is  suffering  from  a  profound 
toxaemia,  do  all  that  is  possible  to  avoid  putting  any  extra 
strain  on  any  tissue,  but  assist  the  tissues  to  neutralise  or 
eliminate  the  virus.  Therefore  from  the  very  beginning  of  the 
"feeling  unwell"  put  the  patient  under  mosquito  netting, 
and  forbid  getting  up  to  pass  water  or  motions,  or 
sitting  up  in  bed.  This  action  will  rest  the  muscular  and 
vascular  symptoms.  In  the  next  place,  knowing  the  extreme 
sensitiveness  of  the  alimentary  tract,  avoid  irritating  it,  for  the 
least  irritation  will  hasten  the  intense  congestion  of  the  mucous 
membrane  and  bring  on  black  vomit.  Nature  will  probably 
remove  from  the  stomach  by  an  early  vomit  its  contents. 
Therefore  it  is  not  the  stomach  that  requires  clearing  but  the 
lower  gut.  This  can  best  be  done  by  a  good  rectal  enema. 
There  is  no  necessity  for  calomel  provided  an  enema  is  handy. 

208 


FlG.  18. — A  Mosquito-screened  Ambulance  for  the  removal  of  cases  of  Yellow  Fever 
to  Hospital.      New  Orleans,  1905. 


[To  face  p.  20S. 


RULES  OF  TREATMENT  209 

Those  who  have  experienced  the  value  of  an  ample  warm  saline 
enema  inform  me  that  there  is  nothing  equal  to  it  for  the  relief 
it  brings.  In  this  way  the  alimentary  tract  is  cleaned  out  with- 
out putting  any  extra  strain  on  that  viscus.  Thirst  will  be  early 
noticed ;  again  this  is  a  natural  reflex,  and  the  patient  should  be 
allowed  abundance  of  simple  alkaline  mineral  waters.  By  this 
means  the  blood  pressure  will  be  kept  up  and  the  secretion  from 
the  kidneys  maintained.  Solid  food  should  under  no  circum- 
stances be  given  in  the  early  stages  of  the  disease.  If  it  is 
given,  gastric  fermentation,  followed  by  congestion,  will  be  the 
result;  therefore  avoid  solid  food.  Later,  if  the  patient  shows 
signs  of  great  prostration  or  collapse,  stimulate  with  champagne. 
It  may  be  necessary  to  maintain  the  blood  pressure  by  normal 
saline  enemata.  Following  these  lines  of  treatment,  and  with 
constant  nursing,  all  authorities  are  agreed  that  at  no  stage  in 
the  disease  should  hope  be  given  up.  For  the  further  guidance 
of  the  medical  officer  I  reproduce  the  more  detailed  treatment 
advocated  by  Dr  Guiteras  of  Havanna,  who  has  had  an  extensive 
experience. 

The  following  guiding  rules  in  treatment,  given  in  a  recent 
lecture  by  Dr  Wolferstan  Thomas,  who  has  himself  had  yellow 
fever,  and  is  now  in  charge  of  the  yellow  fever  station  on  the 
Amazon,  are  of  practical  value,  and  I  reproduce  them  for  the 
guidance  of  the  medical  attendant : — 

"  The  most  important  points  in  the  management  of  yellow 
fever  cases  are  nursing,  absolute  rest  in  bed,  restriction  of  all 
nourishment  for  the  first  few  days,  the  use  of  alkaline  waters,  and 
the  cautious  administration  of  drugs.  You  must  make  your- 
selves responsible  for  the  entire  management  of  the  case,  and 
should  : — 

"  i.  Obtain  as  full  a  history  of  the  onset  as  possible,  and  of 
the  patient's  habits,  temperament,  etc. 

"  2.  Examine  your  patient  thoroughly,  and  do  not  postpone 
the  examination.  Yellow  fever  is  a  disease  which  runs 
too  rapid  a  course  to  permit  of  any  delay. 

O 


210  *  TREATMENT 

"  3.  Examine  a  fresh  specimen  of  urine.  If  you  have  been 
summoned  within  the  first  twenty-four  hours  it  will 
probably  contain  no  albumin.  Give  orders  to  preserve 
all  the  urine  passed  by  the  patient,  and  arrange  that  the 
necessary  covered  jars  are  provided,  so  that  the  full 
quantity  for  the  twenty-four  hours  can  be  kept.  See 
that  a  special  jar  is  always  ready  for  holding  the  last 
urine  voided. 

"  Give  orders  that  the  patient  shall  urinate  before  the 
bowels  move  or  before  a  clyster  is  given.  This  is 
important,  as  later  on  when  the  amount  of  urine  is 
decreasing,  much  urine  may  be  lost  in  the  bed-pan. 
Examine  the  urine  for  albumin,  and  test  the  reaction  at 
least  twice  daily,  until  convalescence  is  established. 
You  have  to  ascertain  the  time  when  the  albumin 
appears,  and  afterwards  the  information  obtained  from 
the  daily  examination  of  the  urine  as  to  the  amount  of 
albumin,  urea,  and  the  reaction  will  be  one  of  the  most 
important  guides  to  the  prognosis  and  management  of 
the  case.  Albumin  is  generally  present  in  this  disease, 
appearing  between  the  second  and  third  day.  In 
severe  cases  it  may  only  appear  for  a  few  hours.  In 
some  cases  it  is  never  found  throughout  the  course  of 
the  disease. 

"  4.  Obtain  a  trained  nurse.  Too  much  care  cannot  be  given 
to  the  patient,  and  severe  cases  will  require  two  trained 
nurses.  In  default  of  trained  nurses  your  patient  will 
suffer,  but  it  will  not  be  your  fault. 

"  5.  Give  instructions  to  have  the  temperature,  pulse,  and 
respirations  taken  and  recorded  every  two  to  four  hours, 
and  check  the  results  by  doing  it  yourself  at  least  twice 
in  every  twenty-four  hours. 

"  6.  Order  the  patient  to  be  screened  both  day  and  night. 
Do  not  fail  to  insist  on  the  utmost  care  being  taken  to 
prevent  Stegomyia  feeding  on  the  patient.     The  lives  of 


o    o 

<L>     — 


«  2 


o     > 


GUITERAS  ON  TREATMENT  211 

all  non-immunes  depend  in  a  great  measure  on  this 
being  observed.  Even  if  you  have  not  made  a  positive 
diagnosis,  so  long  as  there  is  the  least  suspicion  that  it 
may  possibly  be  yellow  fever,  your  duty  is  to  insist  on 
the  screening.  The  screening  saves  your  patient  from 
being  annoyed  by  mosquitos,  and  is  an  educational  factor 
to  the  general  public.  If  it  is  a  case  of  yellow  fever,  and 
over  the  fourth  day  of  the  disease,  the  patient  is  non- 
infective,  and  screening  is  not  absolutely  necessary. 

"  Yellow  fever  is  a  disease  which  allows  of  little  delay.  It 
runs  its  course  in  a  few  days,  and  you  must  be  prepared  to  offer 
battle.  Fortunately  many  cases  are  of  a  mild  type,  and  unless 
something  exceptionally  wrong  is  done  the  case  will  recover. 
Such  cases  are  good  for  your  reputation,  and  as  yellow  fever 
exacts  a  heavy  toll,  and  as  it  will  probably  be  your  misfortune 
to  lose  many  cases,  you  will  need  them.  No  one  who  treats 
many  cases  of  the  disease  can  avoid  losing  a  certain  percentage 
of  his  patients.  There  is  no  panacea  for  yellow  fever  as  there  is 
for  malaria,  but  a  good  physician  can,  by  his  management  of  the 
case,  markedly  reduce  the  mortality. 

"  Eliminative  and  supporting  measures,  with  the  reduction  of 
the  congestion,  should  be  our  aim.  Briefly,  we  can  say  that 
treatment  depends  on  nursing,  abstinence  from  all  food,  rest  in 
bed,  and  hydrotherapy  in  the  form  of  alkaline  waters,  to  act  as 
mild  diuretics.  Water  is  a  very  powerful  remedy  in  this  disease, 
and  should  you  ever  have  to  treat  many  cases  of  yellow  fever,  you 
will  be  surprised  at  the  number  of  patients  that  recover  without 
any  other  treatment  than  alkaline  waters  and  good  nursing." 

Hints  upon  Treatment  of  Yellow  Fever,  based  upon 
those  practised  by  dr  guiteras  of  havanna 

"  The  statistics  of  the  mortality  in  our  hospital  show  the 
importance  of  early  treatment  in  yellow  fever :  not  that  we 
have  any  specific  that  must  be  applied  at  the  beginning  of  the 


212  TREATMENT 

attack,  but   that   rest   in  bed   constitutes  an  important   factor 
in  the  treatment. 

"  Excepting  the  administration  of  a  laxative  and  the  employ- 
ment of  some  palliative  measure,  nothing  else  has  been  done 
here  in  the  first  forty-eight  hours,  or  even  through  the  whole 
attack  in  mild  cases  where  there  was  no  special  indication. 

"  Our  treatment  here  is  published  in  detail  in  an  article  by 
Major  Gorgas,  U.S.A.,  in  the  Journal  of  the  Association  of 
Military  Surgeons  for  October  1903. 

"  We  put  the  patient  to  bed  at  once  and  make  him  keep  the 
horizontal  position.  Clean  linen  for  the  bed  and  person  should 
be  furnished  plentifully.  Windows  and  doors  are  kept  open 
(mosquito-screened),  only  avoiding  direct  draughts.  Quarters 
should  be  very  clean.  Patients  seem  to  do  best  when  treated  in 
tents  or  newly  constructed  frame  buildings. 

"  The  skin  is  cleansed  and  rubbed  with  hot  water  and  soap  on 
admission.  It  is  not  unreasonable  to  suppose  that  these 
measures  may  lessen  the  chances  of  secondary  infections,  which 
may  be  the  cause  of  the  hemorrhagic  manifestations. 

"  Water  is  given  freely  through  a  drinking-tube.  From  50  to 
80  oz.  of  fluid  are  given  in  the  twenty-four  hours.  "Pleasant 
alkaline  waters  and  infusions  and  ginger  also  are  given.  The 
patient  is  not  allowed  to  sit  up  to  empty  bladder  or  rectum. 

"  Something  is  done  at  the  same  time  to  relieve  suffering, 
and  gain  the  confidence  of  the  patient.  External  applications  : 
sinapisms,  ice,  liniments.  If  the  temperature  be  very  high  the 
surface  is  sponged  with  cool  water  and  alcohol,  or  an  enema  of 
cold  water  is  given. 

"  Phenacetin  may  be  given  to  relieve  pain  at  night,  if  neces- 
sary once  or  twice,  but  should  not  be  insisted  upon. 

"  The  first  symptom  that  is  likely  to  call  for  special  treatment 
is  vomiting.  If  the  bowels  have  not  acted  since  the  initial 
purge,  seidlitz  powder  in  broken  doses  to  mix  in  the  stomach,  or 
minute  doses  of  calomel  or  effervescent  magnesia,  is  given.  If 
the  vomiting  is  persistent,  the  administration  of  liquids  by  the 


TREATMENT  213 

mouth  is  discontinued,  and  only  cracked  ice  is  given,  and  rectal 
injections  of  warm  physiologic  salt  solution.  If  the  rectum  has 
not  been  irritated  by  frequent  purgation  this  can  be  kept  up 
with  advantage.     Milk  may  be  added  later. 

"  Cocaine  tablets  and  ice  applied  to  the  throat  are  used  with 
advantage  in  vomiting. 

"  When  black  specks  appear  in  the  vomit,  tincture  of  the 
chloride  of  iron,  5  gtt,  every  two  or  three  hours,  is  usually  given, 
with  a  little  glycerine  and  lemon  juice.  For  haemorrhage  from 
the  mouth  an  antipyrine  wash  is  used. 

"  The  remainder  of  the  treatment  reduces  itself  to  sustaining 
the  strength  of  the  patient,  and  stimulating  the  action  of  the 
heart  and  kidneys  by  the  judicious  use  of  strychnia,  digitalis, 
and  alcohol :  the  two  former  by  the  hypodermic  method  and 
the  latter  by  the  mouth  or  rectum.  Alcohol  is  not  well  borne  in 
large  doses.  The  same  may  be  said  of  strychnia.  Champagne 
is  the  best  form  of  alcohol. 

"  Cold-water  rectal  injections  and  calomel  as  a  diuretic  are 
tried  in  suppression  of  urine. 

"  The  prolonged  typhoid  cases,  often  marked  by  pronounced 
jaundice,  require  alcohol  and  strychnia.  Chlorate  of  potash  is 
given  with  apparent  advantage ;  in  convalescence  muriatic  acid 
and  nux  vomica. 

"  Feeding  with  milk  and  lime-water  is  commenced  on  the 
third,  fourth,  and  fifth  day.  The  quantity  of  milk  is  gradually 
increased. 

"  About  the  ninth  day  a  mild  solid  diet  may  be  ordered. 

"  Very  mild  cases  have  recovered  completely  in  ten   days. 

Others   will   require   the   use   of  peptonised   food,  tonics,  and 

massage." 

References 

Perna  (Luis) — "The  Treatment  of  Yellow  Fever,"  Sanidad  y  Beneficiencia, 

1909. 
SOLOMON  (L.  F.)— "The  Treatment  of  Yellow  Fever,"  In  History  of  Yellow 

Fever  by  Augustin,  New  Orleans,  1909. 
Thomas  (W.) — "Yellow  Fever,"  Annals  of  Tropical  Medicine,  1910. 


214 


DEATH-RATE 


Mortality  Rate 

The  very  high  death-rate,  nearly  ioo  per  cent.,  this  year, 
1910,  in  the  outbreaks  of  yellow  fever  in  West  Africa,  was  a 
matter  of  considerable  astonishment  and  perplexity  to  observers. 
But  on  the  contrary  such  a  high  death-rate  was  to  be  expected, 
especially  in  a  country  where  medical  men  were  on  the  look- 
out for  the  typical  severe  forms  of  the  disease.  Naturally  in  any 
disease  the  mortality  must  be  very  high  if  the  severe  forms  form 
the  bulk  of  those  diagnosed.  In  my  opinion  this  apparent  high 
rate  is  a  positive  proof  that  there  were  many  other  cases  of 
mild  yellow  fever  which  escaped  detection.  Had  all  cases  been 
diagnosed,  I  am  convinced  that  the  rate  would  have  been 
very  much  less.  Therefore  the  fact  that  during  this  year,  1910, 
a  very  large  number  of  the  cases  died,  does  not  mean  that  West 
African  yellow  fever  is  worse  than  in  other  parts  of  the  world. 

Another  factor  which  very  materially  affects  the  death-rate 
in  any  epidemic  is,  whether  the  medical  men  are  expecting  the 
disease  or  not,  whether  it  bursts  on  them  as  it  were,  or 
whether  they  are  expecting  it.  Yellow  fever  cases  carefully 
nursed  from  the  onset  are  not  so  fatal  as  is  usually  supposed. 
Blair's  table  of  mortality  rate  for  the  various  ages  based  upon 
West  Indian  data  is  perhaps  applicable  to  West  Africa,  and 
I  insert  it ;  but  it  must  always  be  well  understood  that  until 
the  mild  forms  are  recognised  no  death-rate  approaches 
accuracy : — 

Yellow  Fever  Percentage  Death-rates  for  Different  Ages  according 

to  Blair 
Under  15  years 
From  15  to  20  years 
„      20  „  30      „ 


30  „  40 

40  „    50 
50  on   . 


24-39  per  cent. 

23-44 

28-45 

19-90 

21-91 

22-22 


Children  usually  get  the  disease  in  a  very  mild  form,  and 
one  not  easily  recognised. 


DEATH-RATE  ACCORDING  TO  AGE 


215 


According  fo  Lazard,  in  the  New  Orleans  epidemic,  out  of 
430  deaths,  the  following  are  the  total  deaths  for  various  ages  : — 


1  to  2 

years 

8 

3i  to  35 

years  . 

36 

3  „  5 

)>     • 

11 

36  »   4o 

J> 

47 

6  „  10 

» 

,   16 

4i  „  45 

JJ 

36 

11  »  15 

»     • 

•   38 

46  „  50 

JJ 

23 

16  „  20 

>> 

•   56 

51  „  60 

JJ     • 

27 

21  „  25 

» 

•   56 

61  „  70 

JJ     * 

10 

26  „  30 

jj     • 

•   6S 

7i  „  75 

JJ      • 

1 

By  some  the  death-rate  in  the  New  Orleans  epidemic  was 
estimated  at  13-11  per  cent. 

In  the  Barbados  epidemic  of  1909  the  death-rate  was  42 
per  cent. 

Guiteras  states,  19 10,  that  the  rate  may  vary  from  4  per  cent,  to 
36  per  cent,  and  that  it  may  go  up  as  high  as  92  per  cent.  The 
death-rate  in  one  series  of  227  cases  which  Guiteras  observed 
was  22-7  per  cent.  But,  as  this  observer  points  out,  much 
depends  upon  treatment,  and  especially  on  the  time  when  the 
patient  was  put  under  treatment.  Thus  in  the  experience  of 
the  Las  Animas  Hospital  at  Havanna,  the  death-rate  amongst 
those  admitted  in  the  first  forty-eight  hours  was  17-7  per  cent, 
and  in  those  later  32-3  per  cent.  Everything  therefore  depends 
upon  careful  treatment  from  the  outset. 

In  the  section  devoted  to  race  susceptibility  will  be  found 
further  death-rates,  arranged  according  to  nationality  and  race 
and  length  of  residence  in  the  Colony.  It  is  a  very  old  observa- 
tion that  recent  arrivals  were  more  prone  to  yellow  fever  than 
those  who  had  been  resident  some  time.  It  has  also  often  been 
observed  that  whilst  the  negro  race  is  not  immune  to  yellow 
fever,  as  is  well  shown  in  the  preceding  pages  on  sympto- 
matology in  different  parts  of  the  world,  nevertheless  the 
mortality  rate  and  the  severity  of  the  symptoms  are  less  than  in 
the  case  of  the  white  race. 


PART    III 
PATHOLOGY 


217 


CHAPTER   XIII 

EXPERIMENTAL   PATHOLOGY 

The  exact  pathology  of  yellow  fever  must  remain  obscure  until 
the  virus  has  been  isolated.  In  spite  of  this  great  disadvantage, 
however,  certain  facts  have  come  to  light,  both  as  the  result  of 
very  careful  observation  in  cases  of  yellow  fever,  and  by  con- 
ducting experiments  in  men  and  in  mosquitos,  which  have 
indicated  the  mode  of  action  of  the  virus,  and  have  in  addition 
placed  in  our  hands  a  specific  means  of  combating  the  disease. 

The  Role  of  the  "  Stegomyia  " 

Beauperthuy  drew  attention  from  1850- 1860  in  no  uncertain 
manner  to  the  fact  that  his  long  and  patient  observations  had 
led  him  to  conclude  that  the  agent  which  propagated  yellow 
fever  was  the  Stegomyia  or  "  house-haunting  mosquito,"  and  not 
emanations  from  the  soil.  In  the  second  place,  Finlay  of 
Havanna  came  to  the  same  conclusion  in  1881,  and  succeeded 
in  giving  a  mild  form  of  yellow  fever  to  susceptible  persons  by 
the  bite  of  the  infected  Stegomyia.  Indeed  he  both  proposed 
and  used  this  method  as  a  protective  measure  against  the  severe 
form  of  the  disease.  There  is  no  doubt  that  Beauperthuy  in 
British  Guiana  was  one  of  the  first  to  announce  that  yellow 
fever  was  propagated  by  the  "  house-haunting  mosquito."  It  is 
equally  true  that  Finlay  was  the  first  to  make  direct  experi- 
ments   to    prove    this,   and    I    therefore   insert   the   following 

statement,  made  by  Dr  H.  E.  Durham,  who,  with  the  late  Dr 
219 


220  EXPERIMENTAL  PATHOLOGY 

Walter   Myers,   were   sent   out   by   the    Liverpool    School   of 
Tropical  Medicine  in  1900  to  study  yellow  fever  in  Brazil. 
Dr  Durham  wrote  in  his  report  to  the  school : — 

"  It  is  incontestible  that  Dr  Charles  Finlay,  of  Havanna,  was 
the  first  to  undertake  direct  experiments  to  substantiate  his 
ideas  of  the  part  played  by  the  mosquito  in  the  transmission  of 
yellow  fever.  His  method  was  to  feed  mosquitos  upon  yellow 
fever  patients  (not  later  than  the  sixth  day),  and  then  after  an 
interval  of  from  forty-eight  hours  to  four  or  five  days  to  allow 
them  to  feed  upon  susceptible  persons  ;  the  idea  was  to  produce 
a  slight  attack  of  the  fever  in  order  to  produce  immunity. 

"  At  a  delightful  chat  we  had  with  the  courteous  doctor,  on 
25th  July  1900,  he  told  us  many  details  concerning  his  experi- 
ments, which  were  commenced  so  long  ago  as  1881.  Altogether, 
102  persons  had  been  tried  in  this  manner,  and  in  17 
instances  some  pathogenic  effect  had  followed  the  bite ;  this 
consisted  in  slight  fever  appearing  about  the  fifth,  sometimes 
as  late  as  the  fourteenth  day. 

"  In  no  instance  was  there  a  definite  attack  of  yellow  fever 
as  the  result,  but  Dr  Finlay  thought  that  a  certain  immunity 
had  been  conferred,  since  only  four  of  these  persons  died  of 
yellow  fever,  though  the  cases  were  followed  out  to  ascertain 
their  after  history,  in  some  cases  for  four  years. 

"  Naturally  it  was  not  possible  to  exclude  intercurrent 
infections  by  thus  working  in  an  endemic  centre,  still  the 
mode  and  kind  of  experiment  which  has  since  led  to  more 
definite  results  was  laid  down. 

"  The  kind  of  mosquito  used  by  Dr  Finlay  was  the  Stegomyia 
fasciata  (it  was  referred  to  in  his  papers  as  Culex  mosquito)  ;  he 
selected  this  kind  on  account  of  its  town-dwelling  habits." 

Fomites,  cadaver,  and  excreta,  not  infectious. — After  many 
years  of  intense  and  bitter  controversy,  it  became  universally 
recognised  that  yellow  fever  was  not  contagious  from  man  to 
man.  That  the  clothes  and  bedding  no  matter  how  contamin- 
ated by  the  patient,  were  non-infectious.  That  the  exhalations 
of  the  patient,  the  vomit,  excreta,  and  the  mucous  discharges 


EXTRINSIC  INCUBATION  PERIOD  221 

from  the  conjunctiva,  were  non-infectious.  Numerous  direct 
experiments  had  been  tried  on  man  with  negative  results  (Mott, 
Blair,  and  others). 

Extrinsic  incubation  period  {Carter  and  Reed). — The  above 
observations,  together  with  a  close  investigation  of  the  dates 
upon  which  subsequent  cases  of  infection  followed  the  first  ones, 
pointed  to  the  virus,  or  infection  residing  in  some  agent  other 
than  man.  Harrison  and  Moxley  enunciated  this  opinion  in 
Barbados,  and  Carter  of  the  United  States  reasoned  that  the 
agent  must  be  the  mosquito  (see  epidemiology). 

Thus  by  a  process  of  exclusion,  direct  observation  and 
epidemiological  considerations,  men's  minds  were  directed  to 
the  mosquito  as  the  probable  agent,  and  it  was  of  course 
enormously  strengthened  by  Ross's  observations  upon  the 
Anophelines.  We  now  know  that  the  virus  of  yellow  fever 
requires  an  incubation  period  of  about  twelve  days  in  the 
Stegomyia,  before  the  latter  is  capable  of  communicating  the 
virus  to  a  susceptible  person. 

This  period  is  known  as  the  extrinsic  incubation  period. 
Once  the  Stegomyia  is  infected,  it  remains  so  for  a  very  con- 
siderable period.  Three  months  has  been  stated  as  the  result  of 
observation,  but  the  maximum  limit  has  not  yet  been  ascer- 
tained. For  practical  purposes  it  is  sufficient  to  know  that  the 
Stegomyia  infected  in  the  autumn  of  one  year  can  carry  over 
infection  into  the  following  year,  and  this  explains  the  often 
repeated  observation,  that  yellow  fever  is  exceedingly  liable  to 
break  out  several  months  after  an  epidemic  was  supposed  to 
have  died  out. 

Direct  inoculation  experiments. — The  ground  having  been 
prepared  in  the  manner  described  above,  it  was  left  to  four 
United  States  Marine  Hospital  Service  medical  men  to  see  if  it 
was  possible  to  infect  man  with  Stegomyice  which  had  fed  on  a 
yellow  fever  patient.  The  results  of  these  inoculation  experi- 
ments are  detailed  under  experimental  yellow  fever  (p.  ioo). 
They  proved  conclusively  that  the  Stegomyia  could  transmit  the 


222  EXPERIMENTAL  PATHOLOGY 

virus  of  yellow  fever.  A  few  experiments  with  other  species  of 
mosquito  were  negative,  but  were  not,  however,  carried  out 
upon  a  sufficiently  large  scale  to  make  absolutely  positive  one 
way  or  the  other. 

Hereditary  transmission  of  the  yellow  fever  virus  in  the 
mosquito. — Several  experiments  have  been  made  to  determine 
whether  the  adult  infected  Stegomyia  can  transmit  infection  to 
the  ova  and  larva  as  happens  in  the  case  of  the  tick,  as  shown 
by  Dutton  and  Todd. 

The  French  Commission  under  Marchoux  obtained  one 
positive  result.  On  the  other  hand,  Guiteras,  Reed,  Carroll, 
Agramonte,  and  Rosenau  obtained  uniform  negative  results. 
The  question  is  therefore  still  open  and  is  worthy  of  further 
research. 

Intrinsic  incubation  period. — From  the  above  experiments,  it 
was  demonstrated  that  the  incubation  period  in  man  was  at 
least  six  days,  a  period  which  coincided  with  the  results  of  direct 
clinical  observation. 

The  further  very  remarkable  fact  was  also  proved,  namely, 
that  the  duration  of  infectivity  in  man  was  very  short,  limited 
apparently  to  the  first  three  days  of  illness,  during  which  time 
only  the  virus  appears  to  be  present  in  the  circulation,  for  after 
the  third  day  the  patient  ceases  to  be  infectious.1  We  know,  in 
support  of  these  direct  experimental  observations,  that  the 
making  of  post-mortem  examinations  upon  yellow  fever  cases  is 
unattended  with  risk  of  infection.  I  have  myself  made  very 
many,  and  did  not  contract  the  disease. 

Blood  inoculation  experiments. — A  series  of  direct  inoculations 
into  non-immunes  was  made  by  Reed,  Carroll,  and  Agramonte, 
from  the  blood  of  patients  suffering  from  yellow  fever  during  the 
first  three  days  of  illness.     In  each  instance  there  resulted  an 

1  It  is  probably  true  that  the  statement  that  the  virus  is  limited  to  the 
first  three  days  of  the  disease  is  too  dogmatic.  All  that  we  can  state 
positively  is  that  the  virus  is  present  during  the  first  three  days ;  but  a 
sufficient  number  of  experiments  have  not  been  made  to  exclude  the 
presence  of  the  virus  on  subsequent  days. 


NATURE  OF  THE  VIRUS  223 

attack  of  fever  as  detailed  in  the  preceding  pages.  These  experi- 
ments proved,  like  the  Stegomyia  experiments,  that  the  virus 
existed  in  the  blood  during  the  first  three  days  of  the  attack. 

Experiments  were  also  made  to  make  certain  that  the 
disease  induced  by  inoculation  was  not  merely  a  toxaemia,  but 
the  result  of  the  multiplication  of  the  virus  in  the  bodies  of  the 
inoculated ;  for  this  purpose  Stegomyia  were  fed  on  the  blood  of 
those  inoculated,  and  it  was  shown  that  Stegomyia  so  infected 
could  transfer  the  virus  to  the  non-immune.  In  the  same  way, 
it  was  proved  that  the  blood  of  those  inoculated  contained  the 
virus,  and  that  the  blood  when  reinoculated  into  a  non-immune 
could  produce  the  disease. 

Lastly,  experiments  were  made  to  ascertain  whether  the 
virus  was  capable  of  passing  through  a  Berkefield  or  Chamber- 
land  filter,  and  it  was  found  that  it  could  pass,  because  the 
filtrate  could  give  rise  to  an  attack  of  yellow  fever  when 
inoculated  into  a  non-immune.  This  same  fact  has  been 
observed  in  the  case  of  certain  other  diseases.  It  has  also 
been  shown  that  the  yellow  fever  virus  is  very  sensitive  to 
heating  and  that  it  is  readily  killed. 

These  various  experiments  have  started  numerous  investiga- 
tions to  try  and  isolate  or  demonstrate  the  virus,  but  hitherto 
without  a  very  definite  result. 

The  virus. — Before  the  Reed-Carroll  experiments  already 
alluded  to,  Sanarelli  and  others  had  maintained  that  the  virus 
was  a  bacillus  which  could  be  isolated  in  all  cases  of  yellow 
fever.  This  was,  however,  disproved,  and  in  any  case  it  could 
not  explain  the  period  of  incubation  in  the  Stegomyia,  for  it  was 
obvious  that  the  transference  of  the  yellow  fever  virus  by  the 
Stegomyia  was  not  mechanical  as  Finlay  himself  once  thought. 

It  is  reasonable  to  suppose  that  whilst  in  the  body  of  the 
mosquito,  the  virus  is  undergoing  some  change.  Yet  what  that 
change  may  be,  whether  like  that  described  by  Ross,  in  the  case 
of  the  malaria  protozoon  in  the  anopheles,  is  not  yet  known. 

Numerous  attempts  to  demonstrate  an  organised   virus   in 


224  EXPERIMENTAL  PATHOLOGY 

the  salivary  glands  of  the  Stegomyia  have  absolutely  failed. 
Microscopical  and  cultural  analyses  of  the  tissues  and  blood  of 
infected  man  have  also  so  far  yielded  mostly  negative  results. 

Blood  examination. — Otto  and  Neumann  made  a  very  long 
series  of  observations  of  the  blood  of  yellow  fever  patients  using 
the  ultramicroscopic  method,  and  found  very  minute  particles 
both  in  the  blood  and  cerebro-spinal  fluid,  but  they  attached  no 
importance  to  their  presence. 

More  recently  Seidelin  has  recorded  the  presence,  in  some 
cases  of  yellow  fever,  of  minute  intracorpuscular  bodies  having  a 
ring  or  an  amoeboid  form,  and  pigmented.  He  also  describes 
some  free  forms  in  the  blood,  and  has  later  demonstrated  the 
presence  of  intracorpuscular  and  intracellular  elements,  in  sections 
of  organs,  especially  in  the  kidneys. 

Schaudinn  surmised  that  the  cause  of  yellow  fever  might  be 
found  to  be  a  spirochete,  and  recently  Stimson  has  described  a 
spirochete  in  the  tubules  of  a  kidney  from  a  case  of  yellow  fever. 

At  one  time  many  observers  came  to  the  conclusion  that 
the  virus  was  bacterial.  The  B.  icteroides  of  Sanarelli, 
the  bacillus  of  Sternberg,  attracted  considerable  attention  at 
the  hands  of  bacteriologists.  Durham  and  Myers  found  an 
influenza-like  bacillus  in  the  cases  of  yellow  fever  which  they 
examined.  Careful  detailed  analysis  has,  however,  shown  that 
none  of  these  bacteria  can  be  regarded  as  the  causative  agents. 
They  are  mere  epiphenomena,  similar  to  the  numerous  varieties 
of  higher  fungi,  which  still  earlier  observers  had  demonstrated 
in  cases  of  yellow  fever. 

Blood  counts. — According  to  Durham  and  other  observers, 
there  is  a  marked  leucopenia  in  the  final  stages  of  yellow  fever. 
At  the  same  time  Durham  points  out  that  there  is  an  increase 
in  the  leucocytes,  in  the  capillaries,  in  the  internal  organs. 
According  to  Sodre  and  Couto,  hypoleucocytosis  is  most  marked 
in  the  severer  forms  of  yellow  fever,  and  less  so  in  the  milder. 
The  polynuclear  leucocytes  are  relatively  increased. 

Experiments  upon  animals. — This  promising  line  of  research 


EXPERIMENTS  OF  THOMAS  225 

has  been  taken  up  by  Dr  W.  Thomas  in  Brazil,  who  is  employ- 
ing anthropoids  and  other  animals. 

It  is  an  old  observation,  that  in  yellow  fever  epidemics, 
domestic  animals  have  appeared  to  suffer.  Blair  instances  the 
case  of  a  dog  and  of  supposed  cases  in  fowls. 

W.  Thomas  succeeded  in  obtaining  a  reaction  in  guinea  pigs 
four  and  a  half  to  thirteen  days  after  being  bitten  by  infected 
Stegomyia.  The  symptoms  consisted  in  a  rise  of  temperature 
lasting  two  to  three  days,  and  dulness.  He  states  that  after  the 
reaction  the  animals  were  immune  to  subsequent  inoculation, 
and  that  during  the  illness  their  blood  was  capable  of  infecting 
Stegomyia.  In  the  case  of  the  chimpanzee  a  reaction  was 
obtained  five  days  after  infection  by  the  bite  of  an  infected 
Stegomyia.  These  experiments  require  to  be  continued  and 
repeated  on  a  large  scale. 

References  to  Experimental  Data 

Beauperthuy  (Louis  Daniel) — Travaux  scientifiques,  Bordeaux,  1891. 
Harrison  (J.  B.)  and   Moxley  (Sutton)  —  Reports  upon  Experiments 

connected  with  Yellow  Fever,  Barbados,  1884. 
Carter  (H.  R.)  and  Finlay  (C.) — Medical  Record,  vol.  lv.,  1899. 
Finlay  (Carlos) — "  El  mosquito  considerado  hypotecamente  como  ajenta 

de  transmission  de  la  fiebre  amarilla,"  Habana,  1881. 
Seidelin  (Harald) — "Zur  ^Etiologie  des  gelben  Fiebres,"  Berliner  klin. 

Wochenschr.,  1909,  No.  18. 
Thomas  (H.  Wolferstan)— "  The  Results  of  Inoculation  Experiments 

with  Virulent  Blood  of  Yellow  Fever  Cases  or  by  Bites  of  Infected 

Stegomyia  calopus,''  Trans.  Soc.  Trop.  Med.  and  Hygiene,  1909-1910. 
Stimson   (A.    M.)— "Notes  on  a  Spirochete,  found  in  the  Kidney  of  a 

Yellow  Fever  Case,"  Trans.  Soc.  Trop.  Med.  and  Hygiene,  1909- 19 10. 
Hernandez  (Thomas)— "The   Heller  and  Gmelin  Reactions  in  Yellow 

Fever,"  Sanidad  y  Beneficencia,  1909. 
Rosenau  (M.  J.)  and  Goldberger  (J.)— "Attempts  to  grow  the  Yellow 

Fever  Parasite.     The  Hereditary  Transmission  of  the  Yellow  Fever 

Parasite  in  the  Mosquito,"  Yellow  Fever  Institute,  Bulletin  No.  15, 

Washington,  1906. 
Rosenau  (M.  J.),  Parker  (H.  B.),  Francis  (E.),  and  Beyer  (G.  E.)— 

"  Experimental  Studies  in  Yellow  Fever  and  Malaria  at  Vera  Cruz," 

Bulletin  No.  14,  Washington,  1905. 

P 


226  EXPERIMENTAL  PATHOLOGY 

SEIDELIN  (Harald) — "Diazo  Reaction  beim  gelben  fiebers,"  Berliner  klin. 

Wochenschr.,  1909,  19. 
Sanarelli  (G.) — "Zur   Lehre  vom  gelben  Fieber,"  Centralb.  f.  Bad.  u. 

Parasit.,  Abt.  I.,  Bd.  xxvii.,  1900. 
"  Note  on  a  Comparative  Study  of  the  Biological  Characters  and  Patho- 
genesis   of   B.  X.  (Sternberg),    B.    ideroides  (Sanarelli),    and   the 

Hog  Cholera  Bacillus,"  Journal  of  Experimental  Medicine,  vol.  v., 

December  1900. 
Reed  (Walter) — "  Recent  Researches  Concerning  the  Etiology,  Propaga- 
tion and  Prevention  of  Yellow  Fever,"  Journal  of  Hygiene,  vol.  ii., 

1902. 
Laveran   (A.) — "  Sur  la  nature   de  l'agent   de  la   fievre  jaune,"  Comptes 

rendus,  tome  liv.,  1902. 
Marchoux  (E.),  Salembini  (A.),  et  Simond  (P.  L.) — "La  fievre  jaune," 

Ann.  de  Pinslitut  Pasteur,  tome  xvii.,  1903. 
OTTO  und  NEUMANN — "  Studien  iiber  Gelbfieber  in  Brazilien,"  Zeitschr.  f. 

Hyg.  und  hifektkrankheiten,  Bd.  li.,  1905. 
Marchoux  (E.)  et  Simond  (P.  L.) — "La  transmission  hereditaire  du  virus 

de  la  fievre  jaune  chez  le  Stegomyia fasciata,"  Soc.  de  Biologie,  tome 

lix.,  1905. 
Reed  (W.),  Carroll  (J.),  Agramonte  (A.),  and  Lazear  (J.  W.) — 

"The  Etiology  of  Yellow  Fever,"  Amer.  Pub.  Health  Assoc,  i%th 

Meeting,  1900. 
Reed  (W.)  and  Carroll  (J.) — "The  Etiology  of  Yellow  Fever,"  Amer. 

Med.  Soc,  February  1902. 
Carter   (H.    R.) — "The   Methods   of  the   Conveyance   of  Yellow   Fever 

Infection,"  Bulletin  No.  10,  July  1902. 
Parker  (H.  P.),  Beyer  (G.  E.),  and  Pothier  (O.  L.)— "  A  Study  of  the 

Etiology  of  Yellow  Fever,"  Yellow  Fever  Institute,  Bulletin  No.  13, 

1903. 
DURHAM  (H.  F.) — Report  of  the  Yellow  Fever  Expedition  to  Para,  Memoir 

VII.,  Liverpool  Tropical  School,  1902. 
Albertini  (A.  D.) — Revista  de  medicina  tropical,  Habana,  vol.  i.,  1900. 
Reed  (W.),   Carroll  (J.),  and  Agramonte  (A.) — American  Medicine, 

Phila.,  6th  July  1901,  p.  19. 
GuiTERAS  (J.) — American  Medicine,  Phila.,  23rd  November  190 1,  p.  810. 
Pothier  (O.  L.),  Hume  (J.),  Watson  (E.  H.),  and  Couret  (M.)— "A 

Preliminary  Report   on   Cells   found   in   Yellow  Fever  Blood,  with 

Reference  to  their  Etiologie  and   Diagnostic    Significance,"  Journ. 

Amer.  Med.  Assoc,  1905. 
SODRE  (A.  A.  A.)   und   COUTO   (M  ) — Das  Gelbfieber  Specielle  Pathologie 

und  Therapie  Nothnagel,  Wien,  1901,  Bd.  v.,  h.  ii. 


CHAPTER   XIV 

MORBID   ANATOMY  AND   HISTOLOGY 

Pathological  A  natomy  and  Histology 

The  appearances  of  the  grosser  and  finer  lesions  in  yellow 
fever  are  characteristic,  as  characteristic  as  the  symptoms  in  a 
well-marked  severe  case  of  yellow  fever.  Should  there  be  any 
doubt  about  the  diagnosis  of  yellow  fever  during  life,  there 
ought  to  be  no  doubt  after  making  a  post-mortem  examination. 

The  naked  eye  appearances  of  the  body  and  viscera  are  such 
as  cannot  readily  be  mistaken  for  any  other  disease. 

The  skin  is  yellow,  often  appearing  much  more  yellow  than 
during  life  ;  there  are  large  livid  patches  especially  in  dependant 
parts,  but  not  limited  to  them ;  subcutaneous  ecchymoses  are 
frequently  present ;  there  may  be  also  evidence  of  oozing  of 
blood  from  the  nose,  mouth,  conjunctivae,  or  anus. 

On  making  an  incision  into  the  body  there  is  no  sign  of 
wasting  ;  the  body  is  often  well  nourished,  abundant  subcutaneous 
fat,  stained  yellow;  the  muscles  appear  normal.  This  simply 
means  that  the  fever  is  as  a  rule  so  acute  that  there  is  no  time 
for  degeneration  reactions  to  set  in.  The  first  visceral  system  to 
be  carefully  examined  should  be  : — 

The  alimentary  tract. — This  system  invariably  exhibits 
some  degree  of  congestion  ;  very  frequently  the  congestion  is 
intense,  especially  in  the  stomach. 

It  has  been  frequently  observed  that  although  no  black 
vomit  may  have  taken  place  during  life,  yet  after  death  the 
stomach  may  contain    a   large  quantity  of  it.     This   fact   was 

227 


228  MORBID  ANATOMY  AND  HISTOLOGY 

noted  by  Dr  Chichester  in  the  1900  yellow  fever  outbreak  at 
Bathurst  in  West  Africa,  and  has  been  many  times  recorded 
by  other  observers. 

The  gastric  mucous  membrane  has  a  purple  or  haemorrhagic 
appearance,  most  marked,  according  to  some  observers,  towards 
the  cardiac  end.  There  is  invariably  present  in  the  stomach 
some  black  vomit,  or  mucus,  or  watery  serous  fluid  ("white 
vomit ")  tinged  with  blood. 

The  intestines  usually  contain  dark  tarry  material.  Accord- 
ing to  Blair's  table  of  ninety-seven  post-mortem  findings,  the 
oesophagus,  towards  the  cardiac  end,  is  deeply  congested.  In 
one  of  the  autopsies  which  I  made  in  New  Orleans  in  1905,  I 
observed  the  same  cardiac  congestion.  In  Blair's  table  the 
stomach  contained  black  vomit  in  seventy-nine  cases  out  of 
ninety-seven,  and  in  all  cases  it  was  congested.  The  oesophagus 
was  congested  in  a  very  large  proportion  of  the  cases.  The 
duodenum,  the  small  and  large  intestines  were  congested  in 
about  one-third  or  more  of  the  total  cases ;  in  many  instances 
the  contents  were  tarry. 

Enlargement  and  congestion  of  the  mesenteric  lymphatic 
glands  has  been  observed,  but  more  usually  they  appear  normal. 
Durham  and  Myers  have  described  an  enlargement  of  the 
lymphatic  glands  in  a  considerable  proportion  of  their  cases. 
After  the  alimentary  tract  in  importance  comes  the  liver. 
The  liver  is  invariably  altered  in  colour ;  most  frequently  it 
presents  some  shade  of  yellow,  usually  boxwood  colour,  but 
shades  like  bath-brick,  tan,  ochreous  brown,  deep  yellow,  pale 
yellow,  reddish  yellow  are  frequently  recorded.  The  fact  being 
that  there  is  some  shade  of  yellow  with,  in  addition,  some  degree 
of  congestion,  the  latter  may  be  so  pronounced  that  the  liver 
looks  like  a  yellow  "  nutmeg  liver."  Most  observers  agree  that 
the  term  boxwood  covers  most  accurately  the  shade  of  yellow 
which  is  most  frequently  seen.  It  is  not  a  bright  yellow 
colour  such  as  is  sometimes  seen  in  jaundice.  The  neck  of  the 
gall   bladder   may    be    congested ;   this   was    the   case   in   the 


~   S  J 

6  a  5 

—     C   CO 


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I   <    a 


AUTOPSIES  229 

autopsies  made  in  Secondee  this  year,  1910.  Next  in  import- 
ance come  the  kidneys. 

The  kidneys  show  some  degree  of  congestion.  They  may  be 
pale,  fatty,  or  fibroid,  but  in  addition  the  vessels  are  as  a  rule 
congested,  especially  in  the  pyramidal  region.  The  bladder 
should  be  examined  for  the  presence  of  urine.  For  if  it  were 
not  possible  to  test  the  urine  during  life  for  the  presence  of 
albumin,  the  opportunity  should  be  taken  to  do  so,  if  any  urine 
happens  to  be  found  in  the  bladder. 

Vascular  system. — The  noticeable  feature  in  connection  with 
the  vascular  system  is  the  general  congestion  of  the  vessels. 
The  heart  is  very  often  flabby,  but  on  the  other  hand  it  may 
present  remarkably  little  change. 

In  six  post-mortems  which  I  made  in  New  Orleans,  small 
ecchymoses  were  present  on  the  external  and  internal  surfaces. 
Petechias  or  serous  surfaces  generally  are  very  frequently  met 
with  in  yellow  fever. 

Brain  and  spinal  cord. — I  found  the  brain  intensely  congested 
in  one  of  my  autopsies,  and  the  condition  has  been  often 
found. 

Lungs. — As  a  rule  there  is  no  fluid  in  the  pleural  cavities  ; 
they  are  usually  dry.  There  may,  however,  be  considerable 
congestion  of  the  lower  lobes  of  the  lung. 

Spleen. — The  spleen  is  not  as  a  rule  noticeably  altered  ;  it 
is  usually  normal  in  size. 

The  naked  eye  changes  therefore  point  to  the  concentra- 
tion of  the  pathological  changes  in  the  vessels,  stomach, 
intestines,  liver,  and  kidneys. 

Notes  of  Autopsies  made  on  Cases  of  Yellow  Fever 

Case  167,  Post-mortem  No.  8,  New  Orleans,  1905  : — 

26th  August  1905. — Skin  yellow ;  spleen  enlarged  and  dark, 

6|  oz. ;  liver  enlarged,  yellow  red  colour,  not  a  bright  yellow  ; 

kidneys  congested  ;  heart,  ecchymoses  on  surface  ;  muscle  flabby 

and   soft ;    some   bile-stained    fluid    in    pericardium  ;    stomach 


230  MORBID  ANATOMY  AND  HISTOLOGY 

contained     typical     black    contents ;     ecchymoses    in     mucous 
membrane ;  patient  died  on  fifth  day  of  illness. 

Case   162,  Post-mortem  No.  7,  New  Orleans,  1905  : — 
Skin  jaundiced;  spleen   nf  oz.,  slightly  yellow   in  colour; 
liver   very  typical  boxwood    colour ;  pleural  cavity    dry;   heart 
flabby,  pale,  ecchymoses  present ;  kidneys  fatty ;   patient  died 
seventh  day  of  illness. 

Case  180,  Post-mortem  No.  9,  New  Orleans,  1905  : — 

Skin  markedly  yellow ;  muscles  dark  red ;  small  amount  of 

fluid  present   in  pleural  cavity ;  spleen   large,  slaty   in   colour ; 

liver   small,  yellow,  granular,  congested ;   kidneys   large,  fatty, 

ecchymosed ;    pericardium    contains    small    amount    of    fluid ; 

heart   muscle   pale,  ecchymosed ;   lungs  hypostatic  congestion  ; 

mesenteric   glands    enlarged ;   stomach   contains   black   vomit ; 

cardiac  end  of  stomach  deeply  congested  ;  patient  died  fifth  day 

of  illness. 

Case  157 ',  Post-mortem  No.  11,  New  Orleans,  1905  : — 
Lungs,  pleural  cavity  dry ;  no  hypostatic  congestion  ;  liver 
boxwood  colour,  slightly  congested ;  kidneys  normal  in  size, 
slightly  fibroid ;  spleen  j\  oz.,  dark  and  firm  ;  heart,  ecchymoses 
on  surface ;  liver  boxwood  colour,  cirrhotic ;  brain  cedematous, 
deeply  congested  ;  patient  died  eighth  day. 

Case  130,  Post-mortem  No'.  12,  New  Orleans,  1905  : — 
Boy,  aet.  twelve,  mesenteric  glands  enlarged ;  some  fluid  in 
pleural  cavity;  left  lung  deeply  congested;  slight  excess  of 
fluid  in  pericardium,  bile-stained ;  ecchymoses  on  surface  of 
heart ;  spleen  firm,  4  oz.,  deep  slate  colour ;  kidneys  normal 
size,  congested ;  liver  43!  oz.,  of  a  very  typical  tan  colour ; 
pancreas  congested  at  base  ;  died  twelfth  day. 

Post-mortem  No.  13,  New  Orleans,  1905  : — 

Male,  aet.  twenty  ;  brain  deeply  congested ;  lungs  deeply 
congested  at  base ;  heart,  ecchymoses  on  surface ;  liver  yellow 
and  congested ;  kidneys  fatty  and  congested  ;  patient  died  sixth 
day. 

In  1909  I  made  two  post-mortem  examinations  upon  cases 
in    Barbados.     In  one  case  the  liver  was  congested,  but  the 


LIVER  231 

typical  boxwood  colour  was  not  seen  until  the  liver  was  cut 
into.  The  kidneys  were  congested,  and  the  stomach  contained 
dark  bloody  fluid  ;  the  mucous  membrane  was  deeply  congested  ; 
the  pericardial  fluid  was  slightly  bile-stained,  and  the  wall  of  the 
left  ventricle  was  soft.  In  another  case  the  liver  had  the 
characteristic  yellow  colour. 

In  the  1910  West  African  cases  the  liver  invariably  presented 
some  shade  of  yellow  colour ;  in  some  cases  it  was  obscured  by 
the  presence  of  congestion,  so  that  the  liver  resembled  the 
nutmeg  type.  Congestion  of  the  gall  bladder  was  a  feature  of 
some  of  the  cases  at  Secondee.     The  kidneys  and  stomach  were 

also  congested. 

Microscopic  Anatomy 

Liver. — In  my  experience  the  microscopic  appearances  are 
very  constant,  but  they  are  not  peculiar  to  yellow  fever.  Closely 
identical  changes  may  be  seen  in  cases  of  phosphorus  poisoning, 
and  in  other  diseases  accompanied  by  rapid  degeneration  of  the 
liver  substance.  The  degeneration  changes  are  most  marked  in 
the  hepatic  zone  of  the  liver  lobule.  The  capillaries  in  this  zone 
are  congested,  exactly  as  in  the  nutmeg  liver  of  venous  conges- 
tion the  liver  cells  between  the  capillaries  have  a  dislocated, 
disorganised  appearance,  with  complete  loss  of  their  outlines. 

The  cell  substance  has  often  a  very  characteristic  vacuolated 
or  sponge-like  appearance,  and  stained  with  osmic  acid  it  is 
found  to  be  loaded  with  fat  droplets,  some  very  minute.  The 
cell  is,  in  fact,  reduced  to  a  fatty  spongework  around  the  nucleus. 
In  these  cases  the  appearance  of  the  cells  more  closely  resembles 
that  seen  in  phosphorus  poisoning  than  in  any  other  disease 
with  which  I  have  had  practical  acquaintance. 

There  is  slight  but  distinct  change  in  the  portal  zone  of  the 
lobule  ;  there  also  appears  evidence  of  cell  proliferation,  and 
there  is  slight  leucocytic  infiltration.  But  these  changes  are  by 
no  means  so  pronounced  as  in  acute  yellow  atrophy,  at  least  in 
my  experience.  The  mucous  membrane  of  the  gall  bladder  on 
section  may  show  considerable  injection  of  the  capillaries. 


S32  MORBID  ANATOMY  AND  HISTOLOGY 

Kidneys. — The  capillaries  in  the  region  of  the  straight  and 
collecting  tubules  may  be  considerably  dilated  and  filled  with 
blood  clot,  and  there  may  be  evidence  of  capillary  congestion 
throughout  the  kidney  and  in  the  glomeruli.  The  congestion 
is,  however,  most  marked  in  the  pyramidal  portion  of  the 
kidney.  In  the  parenchyma  I  have  frequently  observed  dilata- 
tion'1 of  Bowman's  capsule,  and  often  the  presence  of  a  coagulum 
inside  the  capsule.  The  epithelium  of  the  convoluted  tubules 
is  vacuolated  and  contains  fat  droplets,  and  the  cell  substance  is 
granular  and  the  contours  of  the  cells  are  ill  defined.  The 
appearance  of  the  cells  is  very  similar  to  that  seen  in  phosphorus 
poisoning. 

In  the  tubules  hyaline  casts  are  very  common  in  my 
experience,  and  this  fact  has  also  been  observed  by  Otto  and 
Neumann,  Durham,  and  other  observers.  Some  of  the  casts 
may  contain  granular  material  and  red  corpuscles.  There  is  an 
absence  of  leucocytic  infiltration.  The  microscopic  appearances 
are  not  those  found  in  cases  of  blackwater  fever  where  the 
collecting  tubules  contain  pigment. 

Stomach. — The  microscopic  appearance  of  the  wall  of  the 
stomach  corroborates  the  naked  eye  appearance,  and  simply 
shows  dilatation  of  the  capillary  loops. 

Lungs. — Microscopic  sections  show  only  evidence  of  conges- 
tion ;  there  is  no  leucocytic  infiltration. 

Brain. — Apart  from  the  congestion  of  the  vessels,  I  have  not 
observed  any  changes  in  the  grey  substance  of  the  brain. 

The  pathology  of  yellow  fever. — As  stated  in  the  commence- 
ment, it  is  very  difficult  without  knowledge  of  the  virus  to 
explain  the  symptoms  or  tissue  changes  in  yellow  fever. 

There  is  no  doubt  that  fatty  degeneration  of  the  liver  and 
kidney  cells  is  a  very  constant  change.  To  what  is  this  change 
due  ?     It  is  due  to  a  specific  poison,  which,  like  phosphorus,  acts 

1  Durham  lays  stress  upon  the  dilatation  of  the  capsules,  and  considers 
that  the  suppression  of  urine  is  probably  due  to  blockage  of  the  tubules  by 
casts. 


>  K 


.2     *>     S 

CD     u-     13 


S>     rt 


M     *   — i 


THE  URINE  233 

on  the  parenchyma ;  or  is  it  merely  a  secondary  phenomenon 
supervening  in  the  liver  and  kidney  as  the  result  of  bacterial 
invasion  during  the  process  of  death  ?  In  my  opinion  the 
evidence  favours  the  changes  being  induced  by  a  toxaemic 
condition  of  the  blood. 

There  must  be  a  profound  change  in  the  vessel  walls  to 
produce  the  petechias,  haemorrhages,  and  black  vomit  which  are 
so  characteristic. 

With  regard  to  the  mechanism  of  the  jaundice  we  can  say 
very  little.  It  is  often  too  readily  assumed  that  the  bile 
canaliculi  are  blocked  by  the  swollen  cells.  The  jaundice  which 
is  present  is  probably  like  that  seen  in  other  toxaemias  and  is 
"  hcemohepatogenous,"  that  is,  there  is  haemolysis  of  the  blood 
corpuscles  as  well  as  blocking  of  the  bile  ducts  by  the  thickened 
and  altered  bile,  with  the  result  that  the  bile-colouring  matter 
and  salts  are  absorbed  and  not  excreted.  To  what  is  due  the 
suppression  of  urine  ?  Some,  like  Durham,  think  that  as  in 
blackwater  the  tubules  become  blocked;  as  mentioned  above, 
the  histological  changes  in  the  kidney  would  certainly  favour 
this  view. 

The  slowing  of  the  pulse  might  be  accounted  for  by  the 
absorption  of  bile  salts  induced  by  the  disorganisation  of  the 
liver. 

The  Urine  Reactions 

Ehrlictis  diazo  reaction. — Durham  and  Myers  made  a  series 
of  observations,  and  concluded  that  this  test  was  of  no  value  for 
yellow  fever.  Seidelin  examined  for  it  in  22  cases,  and  found  it 
positive  in  about  half  the  cases.  He  does  not  lay  any  stress 
upon  the  reaction  from  the  point  of  view  of  diagnosis.  Albertini 
made  an  examination  of  142  cases,  and  found  the  reaction 
negative  in  130  cases,  and  concluded  that  the  reaction  was  not 
given  in  simple  cases  of  yellow  fever. 

Durham,  in  common  with  all  observers,  lays  great  stress 
upon  the  presence  of  casts  in  the  urine,  and  states  that  it  may 


234  MORBID  ANATOMY  AND  HISTOLOGY 

be  possible  to  find  casts  before  albumin  has  appeared  in  the 
urine. 

Durham  also  found  both  in  his  own  case  and  in  other  cases 
of  yellow  fever  that  picric  acid  and  heat  were  the  most  reliable 
agents  to  use  to  demonstrate  the  presence  of  albumin.  The 
amount  of  albumin  in  the  urine  may  be  so  great  that  a  solid 
coagulum  is  obtained  in  the  test-tube  on  boiling.  All  observers 
are  agreed  that  the  urine  should  be  watched  and  tested  very 
frequently  from  the  commencement  of  illness. 

References 

Blair  (Nathaniel) — Some  Account  of  the    Yellow  Fever  Epidemic  of 

British  Guiana,  London,  1850. 
Marchoux  (E.),  Salembeni  (A.),  et  Simond  (P.  L.) — "La  fievre  jaune," 

Ann.  de  I 'ins titut  Pasteur,  1903  and  1906. 
Otto  und  NEUMANN — "  Studien  iiber  Gelbfieber  in  Brazilien,"  Zeitschr.  f 

Hygiene  u.  Infectionskrank,  1906. 
THOMAS  (W.) — "  Lecture  on  Yellow  Fever,"   Annals  of  Trop.   Med.   and 

Parasitology,  Liverpool,  June  19 10. 
DURHAM  (H.  E.) — Report  of  the  Yellow  Fever  Expedition  to  Para,  Memoir 

VII.,  Liverpool  School  Trop.  Med.,  1902. 
SODRE  (A.  A.  A.)  und  COUTO  (M.) — Das  Gelbfieber  Spec.  Path.  u.  Therapie 

Nothnagel,  Wien,  Bd.  v.,  h.  ii.,  1901. 
Marks — "The  Coagulability  of  the   Blood  in  Yellow   Fever,"   American 

Journal  of  the  Med.  Sciences,  1906. 
Seidelin  (H.)  —  "Preparations  of  Blood  from  a  case  of  Yellow  Fever," 

Trans.  Soc.  Trop.  Med.  and  Hygiene,  London,  191 1,  vol.  iv.,  No.  4. 


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PART    IV 

EPIDEMIOLOGY 


235 


FlG.  30. — Plan  of  the  Island  of  Barbados.  The  dotted  lines  indicate  the  parishes. 
The  black  dots  indicate  the  cases  of  yellow  fever,  and  the  arrows  the  probable 
paths  of  infection.  Note  the  primary  focus  in  Bridgetown,  and  the  scattered 
secondary  foci. 


[To  face  p.  236. 


CHAPTER  XV 

EPIDEMIOLOGY 

I. — Mode  of  Diffusion 

Surgeon-general  Blair,  in  describing  the  spread  of  infection 
in  yellow  fever,  wrote  significantly  as  follows : — 

Its  shifting  lines  of  infection  and  gyratory  movements  suggest 
to  the  imagination  the  attributes  of  insect  life. 

This  great  observer  was  far  nearer  the  truth  than  he 
imagined.  The  same  characteristic  phenomenon  can  still  be 
observed.  It  was  notably  manifest  in  Barbados  during  the 
years  1907,  1908,  and  1 909,  where,  as  the  spot  map  shows,  there 
were  a  series  of  small  outbursts  throughout  the  island. 

The  first  outbreak  was  in  the  chief  town,  Bridgetown,  at  the 
end  of  the  year  1907.  In  the  beginning  of  1908  scattered  cases 
appeared  in  two  other  foci  in  the  island,  and  later  other  centres 
made  their  appearance,  and  small  outbursts  of  18  and  29  cases 
respectively  were  registered.  These  scattered  outbursts  might 
have  been  due  to  two  causes — first,  the  spread  of  infection  from 
the  original  focus  in  Bridgetown  in  1907,  either  by  the  transport 
of  infected  Stegomyia  or,  what  was  more  probable,  the  migration 
of  mild  cases  of  the  disease  from  the  centre  in  Bridgetown  to 
the  outlying  country  districts. 

A  second  alternative,  however,  might  have  been  argued, 
namely,  that  the  secondary  foci  originated  de  novo,  that  is, 
that  the  disease  was  endemic  in  the  island,  and  that  the  out- 
breaks were  recrudescences  of  an  existing  disease. 

In    my   opinion   there   were    weighty    reasons   against   the 

237 


238  EPIDEMIOLOGY 

endemic  view,  chief  amongst  them  the  fact  that  the  natives 
were  those  who  principally  suffered,  which  one  would  not  expect 
if  the  disease  were  endemic  amongst  them.  I  therefore  favoured 
importation,  and  the  view  that  the  original  focus  of  infection  was 
Bridgetown,  from  which  the  disease  then  jumped,  as  it  were,  to 
other  centres  throughout  the  island,  following  the  lines  of  most 
frequent  intercourse. 

To  return  to  Bridgetown.  Early  in  1908  there  was  a  case 
of  yellow  fever  notified,  then  a  lull  occurred  until  later  in  the 
year,  when  a  fresh  outburst  apparently  took  place.  I  say 
apparently,  because  it  is  very  probable  that  in  reality  there  was 
not  this  gap,  and  that  cases  occurred  which  were  not  recognised. 

A  recrudescence  also  followed  in  the  outlying  villages. 

The  total  number  of  cases  in  the  epidemic  was  approxi- 
mately 100.  The  disease  commenced  in  the  chief  town,  Bridge- 
town, in  1907,  spread  slowly  to  the  villages  scattered  throughout 
the  island,  dying  out  in  one  centre  to  appear  afresh  in  another ; 
but  for  the  most  part  appearing  to  remain  quiescent  and  limited 
to  a  few  cases  until  1909,  when  the  disease  appeared  to  burst 
out  afresh. 

In  my  opinion  this  is  only  apparent,  and  due  to  the  fact 
that  the  connecting  cases  passed  unrecognised.  The  great 
interest  of  the  Barbados  epidemic  centred  in  the  large  number 
of  native  black  residents  who  were  affected  ;  more  than  half  the 
cases  were  blacks,  and  there  was  a  high  death-rate.  Another 
interesting  circumstance  was  the  progress  of  the  disease  in  the 
various  centres  in  Barbados.  In  the  chief  town,  Bridgetown, 
the  disease  started  in  a  particular  infected  quarter  of  the  town, 
where  the  Stegomyia  was  very  abundant,  and  where  there  was 
overcrowding.  It  was,  moreover,  the  locality  frequented  by 
sailors.  The  outbreak  was,  however,  attacked  by  prompt 
methods,  such  as  isolation,  fumigation,  and  destruction  of  larvae, 
with  the  result  that  the  outbreak  ceased  in  April  1909. 

In  the  outlying  villages,  however,  the  difficulty  of  complete 
fumigation  of  infected  houses  was  found  to  be  very  great,  and 


FlG.  31.— Spot  Map  of  Yellow  Fever  Cases  in  New  Orleans  1905  Epidemic.  Observe  that  the 
infection  is  concentrated  in  one  particular  area,  viz.,  the  "old  town,"  or  labouring  quarter, 
the  quarter  which,  in  the  time  of  Paget,  was  the  endemic  focus  of  yellow  fever. 


[To  face  p.  238. 


NEW  ORLEANS,  1905  239 

there  is  every  reason  to  suppose  that  a  considerable  number  of 
infected  Stegomyia  escaped  destruction.  The  result  was  that 
sporadic  cases  of  yellow  fever  lasted  well  into  the  autumn  of 
1909.  This  was  the  usual  course  of  the  disease  in  the  days 
before  complete  fumigation  of  houses  in  which  cases  of  yellow 
fever  had  occurred.  The  contrast  of  the  progress  of  the  New 
Orleans  1905  epidemic  to  the  above  is  very  complete. 

New  Orleans  furnishes  an  example  of  an  outbreak  in  a  very 
large  city  of  239,000  inhabitants.  As  the  plan  shows,  the 
disease  centres  in  one  particular  part  of  the  town,  as  in 
Barbados — the  poor,  overcrowded  quarter,  where  the  imported 
labouring  classes  resided.  In  this  area  the  Stegomyia  was 
breeding  in  immense  numbers.  Therefore  there  existed  in 
New  Orleans  the  two  essential  conditions  for  an  outbreak  of 
yellow  fever :  one,  a  very  large  non-immune  population,  and 
secondly,  a  very  large  number  of  Stegomyia.  When,  therefore, 
yellow  fever  .was  introduced,  as  was  supposed,  by  a  ship  arriving 
from  Central  America,  the  conditions  were  favourable  for  an 
outbreak.     It  was,  moreover,  the  hot  season  of  the  year. 

Yellow  fever  was  declared  22nd  July  1905,  but  here,  as  else- 
where, there  can  be  no  doubt  that  the  early  cases  escaped 
detection.  On  12th  August,  105  cases  had  been  declared — this 
was  the  maximum  point.  Analysis  of  the  chart  shows  a  rapid 
rise  to  this  point.  In  the  first  week  in  August,  however,  most 
energetic  prophylactic  measures  had  been  set  on  foot,  and  no 
less  than  70,000  cisterns  had  been  screened,  in  addition  to  a  vast 
number  of  houses  fumigated,  and  the  immediate  isolation  of 
any  case  of  disease  presenting  the  least  suspicious  symptoms. 

The  effect  of  this  is  seen  in  the  curve.  The  vast  bulk  of 
infected  Stegomyia  were  destroyed  by  the  thorough  sulphur 
fumigation  ;  the  supply  of  fresh  ones  had  been  completely  cut  off 
by  the  wholesale  screening  of  cisterns,  the  removal  of  useless 
receptacles,  and  the  abundant  use  of  petroleum  ;  and  finally,  all 
possible  human  carriers  having  been  carefully  screened  and 
watched,  there  was  no  possibility  of  the  disease  gaining  head- 


240  EPIDEMIOLOGY 

way,  and  it  had  to  fall  back.  There  is,  therefore,  a  steady  fall 
during  the  autumn  months,  interrupted  here  and  there  by  a 
sporadic  case  or  two,  but  no  outburst. 

The  most  striking  evidence  of  the  extraordinary  difference 
of  the  results  of  the  prophylactic  measures  adopted  in  this 
campaign  as  compared  with  previous  epidemics  in  New  Orleans 
is  furnished  by  comparison  with  the  number  of  cases  on  corres- 
ponding dates  in  the  previous  epidemics.  Thus,  in  the 
epidemic  of  1898,  2  cases  are  reported  on  24th  July;  on  12th 
August,  there  are  31  new  cases;  on  the  14th,  the  new 
cases  were  134;  steady  increase  takes  place,  and  on  31st 
August  the  new  cases  are  234.  Increase  still  takes  place,  and 
this,  too,  in  spite  of  the  adoption  of  all  the  methods  then  known 
to  science,  and  which  consisted  in  most  rigid  house  quarantine ; 
towards  the  end  of  September  there  is  slight  decrease,  but  in 
the  first  week  in  October  as  many  as  305  new  cases  are 
reported  on  the  4th ;  the  figures  then  slowly  decrease  to  an 
average  of  about  60  new  cases  in  the  first  week  in  November, 
and  after  that  the  frost  brings  the  fever  to  a  close.  The  total 
number  of  cases  amounted  to  13,817,  with  3984  deaths,  as  com- 
pared with  3384  and  443  deaths  in  1905. 

It  would  be  impossible  to  obtain  more  striking  figures  of 
the  thorough  control  which  the  organised  medical  forces  had 
over  the  fever  by  the  end  of  the  first  week  in  August,  and 
solely  by  adopting  one  line  of  attack — the  destruction  of  the 
Stegomyia  fasciata  in  the  houses,  prevention  of  their  breeding 
in  the  water  cisterns,  and  early  recognition  and  screening  of 
the  cases. 

In  Belize,  British  Honduras,  the  small  outbreak  which  I  was 
called  upon  to  investigate,  showed  the  same  history  of  want  of 
recognition  of  the  early  cases,  and  in  consequence  the  "  bolt 
from  the  blue  "origin  of  the  disease  as  it  is  often  termed.  In 
reality  it  is  nothing  of  the  kind,  had  one  the  means  of  diagnosing 
the  early  and  mild  cases.  The  so-called  "  bolt  from  the  blue  " 
is  only  the  sudden  appearance  of  what  seems  to  be  an  isolated 


B     3 


2   a 


YELLOW  FEVER  HOUSES  241 

severe  case  of  yellow  fever.  The  outbreaks  in  West  Africa  this 
year,  1910,  partake  of  the  same  character,  and  there  is  a  sudden 
outbreak  of  fatal  cases  of  yellow  fever  both  in  Freetown  and 
Secondee.  But  as  in  New  Orleans,  in  Barbados,  and  in  Belize, 
there  must  have  been  other  cases  unrecognised.  This  state- 
ment raises  the  question  of  whether  yellow  fever  did  not  exist 
all  the  time  amongst  the  natives ;  in  other  words,  whether  it 
was  endemic  or  not.  In  the  case  of  New  Orleans  and  Barbados 
the  evidence  is  in  favour  of  importation ;  in  the  case  of  Belize 
the  evidence  is  about  equal  for  importation  and  the  endemic 
origin.  In  the  case  of  West  Africa,  the  evidence,  in  my  opinion, 
conclusively  points  to  its  endemic  origin. 

In  the  first  place,  importation  could  not  be  proved  ;  in  the 
second  place,  there  were  four  outbreaks  in  towns  separated  from 
one  another.  In  the  third  place,  the  disease  selected  out  the 
whites ;  there  were  very  few  recognised  cases  amongst  the 
blacks.  This  was  not  the  case  in  New  Orleans,  nor  in  Barbados, 
where  the  blacks  suffered  equally  with  all  other  classes  of  the 
community.  Had  the  disease  been  imported  in  West  Africa, 
the  blacks  should  have  suffered  far  more  than  they  did.  The 
inference  therefore  is,  that  the  native  black  inhabitants  had 
been  partially  immunised  by  previous  attacks  of  the  disease;  in 
other  words,  that  the  disease  has  all  along  been  endemic  to  the 
West  Coast  of  Africa. 

Yellow  fever  houses. — In  Barbados  I  was  shown  several 
houses  which  had  the  evil  reputation  that  if  anyone  went  to 
reside  in  them  they  were  very  liable  to  get  yellow  fever.  This 
is  an  old  observation,  which,  in  the  period  before  the  Stegomyia 
doctrine,  appeared  exceedingly  strange.  To-day,  however,  we 
have  a  very  complete  explanation  in  the  Stegomyia  doctrine.  The 
following  report,  written  by  Dr  Durham  in  1900,  to  the  Liverpool 
School  of  Tropical  Medicine,  just  at  the  time  that  the  Stegomyia 
doctrine  was  being  proved  in  Havanna,  is  of  great  interest : — 

"  It  seems  to  be  fairly  definitely  established,"  he  wrote, 
"  that  a  yellow  fever  patient  may  become  a  danger  by  '  infecting 

Q 


242  EPIDEMIOLOGY 

the  house '  in  which  he  is  placed.  Given  that  a  house  is 
*  infected,'  a  visit  by  a  non-immune  person  entails  considerable 
risk  of  contracting  the  malady.  It  is  alleged  by  some  that 
visits  made  at  night  are  more  dangerous  than  those  made 
during  the  daytime ;  but  here  the  evidence  is  not  very  clear, 
and  is  more  of  the  nature  of  an  opinion.  The  nature  of  the 
essential  factor  present  in  an  '  infected  house '  is  as  yet 
mysterious.  One  house  after  another  in  a  street  may  become 
'  infected '  without  any  apparent  intercommunication  of  the 
inmates ;  the  infection  may  skip  over  one  or  more  houses  and 
reappear  at  some  distance.  There  are  those  who  are  bold 
enough  to  predict  in  a  village  that  such  a  house  will  yield  one 
or  more  cases  of  the  fever  on  or  about  a  certain  day ;  and, 
naturally,  they  claim  to  be  true  prophets. 

"  Of  the  interesting  and  important  facts  which  have  been 
ascertained,  those  elucidated  by  Dr  Carter  in  his  study  of 
outbreaks  at  Orwood  and  Taylor  (Miss.)  in  1898,  are  second  to 
none.  The  conditions  were  such  that  the  intervals  between  the 
introduction  of  '  infecting '  cases  and  the  onset  of  secondary 
cases  could  be  followed  with  accuracy.  Dr  Carter  finds  that  an 
interval  of  about  fourteen  to  twenty-one  days  obtains  before  the 
first  secondary  cases  occur.  The  house  is  then  in  an  'infected  ' 
condition,  and  exposure  for  a  few  hours  (for  example,  in  one 
case  four  hours  and  a  half)  can  lead  to  infection,  with  the 
incubation  interval  up  to  the  normal  four  or  five  days.  This 
was  exemplified  to  us  by  the  history  of  a  case  at  Quemados,  for 
which  we  are  indebted  to  Dr  Reed.  In  a  house  which  had 
been  occupied  by  non-immune  officers  last  year,  two  cases 
of  yellow  fever  occurred  this  summer;  one  of  these  was 
unfortunately  fatal.  However,  a  male  and  a  female  nurse 
who  had  been  occupied  in  tending  the  patients  did  not 
acquire  the  disease  until  about  a  fortnight  after  the  death 
occurred.  Other  sources  of  infection  could  be  excluded  in 
these  cases.  No  further  cases  occurred,  as  the  house  was 
cleared  and  liberally  treated  with  perchloride.  The  slight 
epidemic,  however,  spread  to  other  houses  down  the  street, 
although  they  were  detached  and  surrounded  by  a  small  amount 
of  garden  space. 

"  This  curious  and  somewhat  prolonged  interval  is  suggestive 


PERIODICITY  243 

of  a  development  of  the  infecting  factor  in  or  about  some  agent 
or  matter  in  the  domicile.  What  may  be  the  nature  of  this 
supposed  agent  is  not  yet  demonstrated  ;  but  the  suggestion 
propounded  by  Dr  C.  Finlay,  of  Havanna,  some  twenty  years 
ago,  that  the  disease  was  spread  by  means  of  mosquitos,  hardly 
appears  so  fanciful  in  the  light  of  recent  discoveries  in  ague 
conveyance,  as  appeared  in  the  days  when  the  idea  was  first 
broached. 

"  Dr  Finlay's  hypothesis  is  able  to  account  for  several  curious 
points  which  obtain  with  yellow  fever.  Thus  the  limitation  of 
the  disease  to  the  'yellow  fever  zone,'  where  frost  is  unknown, 
the  coincidence  of  yellow  fever  and  rainy  seasons,  the  cessation 
of  the  disease  when  the  temperature  falls  below  a  certain  point, 
and  its  non-recrudescence  in  an  infected  locality  after  a  frost, 
are  all  compatible  with  an  agency,  such  as  a  gnat,  which  becomes 
too  sluggish  to  bite,  or  indeed  which  dies  out  in  unfavourable 
climatic  conditions. 

"  Such  a  theory  also  explains  the  curious  spread  of  the  disease 
from  house  to  house,  which  has  already  been  referred  to. 
Another  point  is  that  the  sanitary  condition  of  a  house  may  be 
good,  and  yet  it  may  be  severely  'infected.'  An  example  of 
this  was  shown  by  the  case  of  one  of  the  leading  hotels  in 
Havanna,  of  good  sanitary  repute,  but  the  source  of  many  fever 
cases  this  summer. 

"  The  above  sketch  will  suffice  to  show  that  some  means  of 
transmission  by  the  aid  of  an  intermediate  host — a  town-loving 
host  for  this  town-loving  disease — is  to  some  extent  more 
plausible  than  might  be  anticipated.  Whether  that  hypothetical 
host  is  of  the  nature  of  a  gnat  remains  unknown." x 

II. — Periodicity  and  Seasonal  Prevalence 

There  is  a  tradition  in  most  tropical  countries  that  yellow 
fever  makes  its  appearance  at  definite  intervals.  Thus  Dr  Pavy 
states  that  "  a  belief  commonly  prevails  in  the  West  Indies 
that  outbreaks  are  periodic.  Its  occurrence  at  intervals  of  time 
may   be    considered    as   well    established ;    but    it   cannot    be 

1  This  was  written  just  prior  to  the  great  discovery  of  Reed,  Carroll,  and 
Agramonte. 


244  EPIDEMIOLOGY 

admitted,"  he  adds,  "  to  be  equally  well  established  that  the 
intervals  are  regular  and  alike  so  as  to  admit  of  being 
calculated." 

The  opinion  at  one  time  prevailed  that  it  might  be  possible 
for  a  traveller  to  calculate  when  a  particular  country,  liable  to 
yellow  fever,  was  or  was  not  safe  to  travel  in. 

Whilst  in  Barbados  in  1909,  investigating  outbreaks  of  yellow 
fever,  I  was  informed  that  this  belief  still  existed,  and  that  the 
period  was  regarded  to  be  thirteen  years.  A  similar  belief  in 
periodicity  has  existed  on  the  West  Coast  of  Africa,  where  the 
period  is  believed  to  be  seven  years. 

In  the  light  of  modern  knowledge  we  can  readily  understand 
how  in  the  days  immediately  preceding  the  great  development 
of  sea-trade,  populations  were  much  more  fixed,  and  therefore  less 
liable  to  fluctuation  than  to-day.  The  influx  of  strangers  was 
far  less  common  than  now  ;  people  resided  many  years  in  a 
tropical  town,  and  did  not  lightly  face  a  long  and  perilous  sea 
voyage  in  a  sailing  ship.  In  consequence  families  grew  up  who 
had  not  been  to  Europe. 

When,  therefore,  an  epidemic  did  break  out,  it  attacked  all 
non-immunes  present  in  the  particular  area.  Those  who  recovered, 
both  children  and  adults,  were  partially  immunised  for  a  term 
of  years,  and,  in  consequence,  there  would  be  an  apparent 
cessation  of  yellow  fever  in  its  severe  or  epidemic  form ;  no 
doubt,  however,  mild  cases  did  occur,  and  were  diagnosed  as 
remittent  endemic  fever. 

After  an  interval  of  some  years,  it  is  probable  that  those 
who  had  yellow  fever  in  their  infancy  had  lost  to  a  considerable 
extent  their  immunity,  and  had  again  become  susceptible. 
Given  a  new  population  consisting  of  a  large  number  of 
inhabitants  who  had  become  non-immunes  and  some  new 
arrivals,  and  the  conditions  were  present  for  an  epidemic ; 
and  this  invariably  did  occur.  To  this  extent  only  is  there 
periodicity.  In  the  present  day,  with  the  daily  arrivals  of 
passengers    by    land    and   sea,   there   is   constant   liability   to 


SEASONAL  PREVALENCE  245 

yellow   fever,   provided    there    are    infected    Stegomyia   in   the 
locality.1 

Seasonal  prevalence. — In  the  older  works  on  yellow  fever, 
much  attention  was  given  to  the  seasons  of  the  year  in  which 
yellow  fever  was  most  prevalent,  and  no  doubt  in  the  older 
days,  seasonable  prevalence  was  much  more  marked  than  it  is 
to-day. 

To-day  pipe-borne  water  supplies  are  common  in  the 
larger  towns.  In  the  old  days  the  inhabitants  had  to  depend 
altogether  on  roof  water  and  wells,  and  this  would  depend  on 
the  rains. 

During  the  rains,  therefore,  more  receptacles  would  be  filled 
with  storage  water,  and  for  many  weeks  there  would  be  a  very 
considerable  increase  in  the  breeding  of  the  Stegomyia.  To-day. 
the  facilities  for  breeding  are,  as  a  rule,  fairly  uniform 
throughout  the  year.  In  all  probability  more  discarded 
receptacles,  such  as  tins  of  all  kinds,  become  breeding-places 
for  the  Stegomyia  during  and  after  the  rains ;  but  in  the  dry 
season  the  tendency  to  store  domestic  water  in  more  receptacles 
would  also  favour  breeding.  Another  factor  which  would 
greatly  influence  the  breeding  of  the  Stegomyia  is  the  external 
temperature. 

It  was  well  known  that  yellow  fever  epidemics  only  occurred 
in  towns  in  North  America  and  in  Europe  in  the  hot  months,  the 
advent  of  cold  put  an  end  to  them  at  once.  In  the  tropics, 
however,  this  factor  does  not  count  to  any  great  degree,  owing 
to  the  far  more  uniform  high  temperature  throughout  the  year. 
Therefore,  outbreaks  are  liable  to  occur  in  any  season,  provided 
that  the  Stegomyia  is  in  sufficient  numbers  and  infection  is 
present. 

In    West   Africa   opinion    seems   to   favour   the   view   that 

1  Faget  pointed  out  the  regularity  with  which  each  successive  batch  of 
poor  immigrants  into  New  Orleans  were  infected  with  yellow  fever  as  soon 
as  they  took  up  their  quarters  near  the  port,  a  quarter  which  appeared  to  be 
a  perpetual  endemic  nidus. 


246  EPIDEMIOLOGY 

yellow  fever  is  most  common  after  the  rains.  Perhaps  the 
months  in  which  the  disease  has  most  frequently  occurred  have 
been  from  April  to  June ;  but  this  might  simply  depend  upon 
the  circumstances  that  at  this  period  there  were  new  arrivals. 
My  analysis  of  the  outbreaks  in  West  Africa  show  that  no 
month  is  free  from  the  disease. 

In  the  West  Indies,  April  to  September  are  perhaps  the 
months  most  frequently  implicated.  It  is  a  very  old  observation 
that  frost  puts  an  end  to  an  epidemic.  We  now  of  course  know 
that  this  is  due  to  the  stoppage  of  breeding  of  fresh  supplies  of 
Stegomyia  and  the  torpidity  of  the  imagos.  But  there  is  no 
doubt  that  infected  Stegomyia  may  hibernate  in  houses  during 
the  cold  weather,  and  become  active  again  in  the  following  year. 
Numerous  cases  of  this  kind  have  occurred  in  Spain  and  in  the 
United  States.  The  same  phenomenon  has  time  and  time  again 
appeared  on  board  ships.  A  ship  with  cases  of  yellow  fever  on 
board  sailed  into  a  cold  region,  and  the  fever  ceased.  On  the 
ship  again  returning  into  a  hot  climate,  yellow  fever  reappeared. 
The  explanation  is  that  the  heat  caused  increased  activity  of 
the  Stegomyia  on  board,  and  no  doubt  also  caused  them  to 
breed. 

Trade  Routes  and  Yellow  Fever 

Disease  follows  trade  routes  whether  by  land,  sea,  river,  or 
rail.  In  West  Africa  there  has  existed  abundant  communica- 
tion between  the  colonies  both  by  land,  sea,  and  river.  So  that 
admitting,  for  argument,  that  yellow  fever  was  introduced  some 
time  in  a  past  century  into  some  colony  or  district  in  West 
Africa,  it  could  have  readily  spread  to  all  other  parts  of  the 
West  African  Coast,  for  the  conditions,  no  doubt,  have  all  along 
been  ideal :  abundance  of  Stegomyia  and  abundance  of  natives. 
Therefore,  yellow  fever  having  once  been  introduced  into  West 
Africa,  we  must  admit  that  it  could  readily  have  spread  through- 
out the  colonies. 

This  very  fact  would  have  necessarily  led  to  the  disease 
becoming   in   a   few   years   endemic,  so  that   for   all    practical 


ENDEMICITY  247 

purposes  it  may  be  freely  assumed  that  yellow  fever  is  to-day 
endemic  in  West  Africa,  for  at  no  period  in  the  history  of  West 
Africa  were  effective  measures  taken  to  prevent  the  spread  of 
the  disease  from  one  colony  to  another,  by  means  of  the 
innumerable  channels  of  intercourse  both  by  land,  river, 
and  sea. 

Therefore  in  seeking  an  explanation  of  the  outburst  of 
severe  yellow  fever  amongst  the  whites  at  Freetown,  Secondee, 
Axim,  and  Saw  Mills,  this  year,  1910,  it  is  not  necessary  to  look 
for  some  ship  which  might  have  conveyed  the  infection  from 
Central  America. 

The  infection  was  at  hand  in  the  native  population.  There- 
fore the  question  of  the  transference  of  yellow  fever  by  trade 
routes  in  West  Africa  is  under  present  conditions  of  little 
moment,  compared  with  the  infinitely  more  vital  questions  of 
eliminating  the  disease  from  the  natives  by  Stegomyia  destruc- 
tion, and  by  protecting  the  non-immunes  by  means  of  segrega- 
tion. 

It  is  a  very  old  observation  that  from  the  moment  Europeans 
settled  amongst  native  races  in  the  tropics  and  began  to  trade, 
yellow  fever  appeared.  When  large  populous  trading  centres 
grew  up,  such,  for  example,  as  those  of  Havanna,  Rio,  and  New 
Orleans,  then  these  became  the  foci  from  which  yellow  fever 
spread  to  other  parts. 

Ships  are  especially  liable  to  transmit  disease  from  one  part 
of  the  world  to  another.  In  the  seventeenth,  eighteenth,  and 
nineteenth  centuries,  North  America  and  Europe  became 
repeatedly  infected  by  the  arrival  of  infected  ships. 

Yellow  fever  was  so  common  in  commercial  ports  that  it 
came  to  be  looked  upon  as  a  disease  peculiar  to  seaports  ;  but  it 
was  soon  observed  that  the  moment  the  interior  of  the  country 
was  opened  up  through  the  energy  of  miners  or  planters,  that 
yellow  fever  appeared  just  as  formidably  in  the  interior  as  on 
the  coast ;  and  moreover,  that  it  did  not  remain  confined  to 
the  flat  coast-line,  but  ascended  into  the  mountainous  districts. 


248  EPIDEMIOLOGY 

In  other  words,  the  situation  of  a  town  had  nothing  to  do 
with  the  appearance  or  absence  of  the  disease,  given  that  the 
conditions  of  temperature,  water,  and  infected  natives  were 
adequate  and  suitable  to  the  propagation  of  the  Stegomyia, 
yellow  fever  broke  out. 

Miners'  and  prospectors'  camps,  villages  which  sprung  into 
existence  during  railway  construction,  were  all  the  seats  of 
election  of  the  Stegomyia.  They  found  ready  at  hand,  and  in 
abundance,  the  innumerable  odds  and  ends  in  the  shape  of 
discarded  meat,  fruit,  and  condensed  milk  tins,  etc.,  which 
invariably  contain  water  after  a  shower  of  rain,  and  which  are 
always  to  be  found  in  and  around  workmen's  dwellings. 
Moreover,  the  usual  large  collection  of  barrels  necessary  for  the 
storage  of  water,  in  the  newly  erected  settlements  before  the 
pipe-borne  water  supply  is  laid,  furnish  ideal  mosquito  breeding- 
grounds. 

In  connection  with  the  transmission  of  yellow  fever,  as  also 
of  plague,  two  factors  have  always  to  be  taken  into  account : 
man  on  the  one  hand,  and  the  insect  carrier  on  the  other. 
Therefore  in  devising  means  for  combating  these  diseases,  these 
two  aspects  must  be  always  before  the  medical  officers.  The 
various  ways,  for  instance,  in  which  man  and  the  mosquito  may 
elude  his  vigilance  must  always  be  borne  in  mind. 

It  must  be  remembered  also  that  as  in  so  many  other 
instances,  it  is  the  unexpected  which  happens.  In  the  case  of 
man  the  danger  usually  arises  because  the  symptoms  may  be  so 
slight  that  they  escape  detection,  and  persons,  not  knowing  that 
they  are  suffering  from  the  disease,  move  from  place  to  place. 

It  is  for  this  reason  that  the  rigorous  systematic  use  of  the 
thermometer  should  never  be  omitted  in  the  case  of  passengers 
arriving  by  ship  or  train  from  infected  towns.  Under  these 
circumstances  it  is  also  advisable  to  keep  new  arrivals  under 
daily  observation.  It  may  even  be  necessary,  if  there  is 
reasonable  ground  for  suspicion,  to  detain  passengers  in  a 
quarantine  station  or  observation  camp. 


TRANSPORT  OF  STEGOMYIA  249 

i 

In  the  case  more  especially  of  native  permanent  com- 
munities, black  or  Indian-Spanish,  amongst  whom  there  is 
reason  to  suspect  a  mild  endemic  form  of  yellow  fever,  every 
precaution  must  be  taken  to  deflect  the  traffic  so  far  as  possible 
from  them. 

If  the  difficulties  of  supervision  of  travellers  requires  great 
vigilance,  those  attending  the  prevention  of  the  migration  of  the 
Stegomyia  are  still  greater. 

Time  and  time  again  experience  has  taught  us  that  the 
infected  Stegomyia  is  very  liable  to  elude  all  our  vigilance.  It 
may  hide  in  those  parts  of  the  ship  which  were  considered  most 
unlikely,  and  which  were  in  consequence  not  fumigated ;  for 
instance,  they  have  been  discovered  in  the  engine-room  of  a 
ship. 

Since  sailing  ships  have  been  replaced  by  steam-ships,  the 
risk  of  ships  carrying  yellow  fever  has  been,  of  course,  greatly 
reduced  ;  but  it  does  occur,  and  I  have  known  instances  where  a 
stowaway  has  carried  infection,  and  where  infected  mosquitos 
have  been  carried. 

Sailing  ships  are  still  largely  engaged  in  the  coasting  trade 
in  tropical  countries,  and  in  them  the  conditions  are  much  as 
they  were  in  the  eighteenth  century ;  therefore  it  is  imperative 
to  rigorously  inspect  and  fumigate  them.  In  many  places  canoe 
traffic  is  also  largely  made  use  of.  Their  danger  lies  in  the  fact 
that  native  passengers  arriving  by  them  are  in  all  probability 
ambulatory  cases.  This  form  of  traffic  should  therefore  be 
rigorously  guarded,  and  excluded  from  centres  of  population. 
It  is,  of  course,  very  difficult  to  do  this  in  many  countries,  and 
may  entail  the  employment  of  much  additional  assistance. 

Daylight  communication. — It  is  a  useful  practical  rule  to 
remember  that  intercommunication  and  transference  of 
passengers  should  be  carried  out  by  day  rather  than  by  night. 
Practice  shows  that  there  is  less  risk  of  infection  during  day- 
light than  at  night-time.  In  the  years  when  yellow  fever 
appeared  regularly  in  epidemic  form  in  Rio  and  in  Santos,  it 


250  EPIDEMIOLOGY 

was  the  practice  of  merchants  to  leave  these  towns  in  the 
evening  by  train  and  sleep  with  their  families  in  the  country. 
In  the  morning  they  returned  to  town  and  transacted  their 
business  during  the  whole  of  the  day.  A  case  of  yellow  fever 
amongst  them  was  most  unusual  (Sodre  and  Couto). 

Conveyance  by  railroad. — As  in  the  case  of  ships,  so  in  the 
case  of  railway  carriages,  the  Stegomyia  can  be  transported  ;  but 
this  does  not  occur  as  often  as  on  ships.  The  conditions  are  very 
different  on  railway  cars — there  are  usually  strong  currents  of 
air  which  tend  to  sweep  out  mosquitos. 

Conveyance  by  baggage  and  merchandise. — The  danger  of  this 
method  of  transference  is  not  great.  It  may  occur,  however, 
and  where  bales  of  goods  are  packed  in  places  surrounded  by 
native  huts,  and  where  the  Stegomyia  is  swarming,  there  is  a 
risk  of  a  Stegomyia  being  included  in  the  baggage  or  the  bale. 
The  danger  of  Stegomyia  being  found  in  packed  baggage  is 
admitted  by  all  authorities  to  be  small.  When  they  are  carried 
it  is  usually  found  that  they  are  secreting  themselves  in  the 
folds  of  coats  or  dresses  ;  therefore  they  should  be  looked  for  in 
loose  clothes.  Therefore  every  care  should  be  taken  to  pack 
goods  in  the  open,  and  away  from  mosquito  breeding-grounds 
and  native  houses.  This  year,  1910,  objection  was  taken  by  the 
Government  of  the  Gambia  to  the  bales  of  Kola  nuts  packed 
in  Sierra  Leone.  Theoretically  there  was  a  risk,  and  it  would 
have  to  be  contended  with  in  the  case  of  all  yellow  fever  free 
districts. 

Conveyance  by  lighters. — Dr  Durham  investigated  a  number 
of  lighters  at  Para,  employed  for  conveying  merchandise  to  and 
from  the  wharves  to  the  steamers  lying  in  the  river.  He  found 
the  larvse  of  Stegomyia  calopus  in  the  bilge  of  the  covered 
lighters.  On  the  other  hand,  the  open  lighters  were  free,  which 
he  believes  was  due  to  the  presence  of  tarry  matter  mixed  with 
the  water.  He  concluded  that  infected  Stegomyia  could  be 
carried  both  by  the  lighters  and  by  tenders  from  the  shore  to 
the  ships. 


REFERENCES  251 


References 


Carter   (H.   R.) — Shipment  of  Merchandise  from  a   Town  infected  with 

Yellow  Fever,  Treasury  Department,  U.S.  Marine  Hospital  Service, 

Washington,  1899. 
Carter   (H.   R.) — "Are   Vessels    infected  with   Yellow    Fever?"   Yellow 

Fever  Institute,  Bulletin,  No.  9,  July  1902. 
Grtjbbs  (S.  B.) — "Vessels  as  Carriers  of  Mosquitos,"  Yellow  Fever  Institute, 

Bulletin,  No.  11,  March  1903. 
Grubbs    (S.   B.) — "A   Note    on   Mosquitos   in    Baggage,"   Yellow   Fever 

Institute,  Bulletin,  No.  6,  Section  C. 
Souchow    (Edmund) — "Fruit   Vessels,    Mosquitos,   and    Yellow   Fever," 

fournal  of  American  Medical  Association,  13th  June  1903. 


CHAPTER  XVI 

RACE  SUSCEPTIBILITY  AND   IMMUNITY 

A  LARGE  amount  of  misconception  exists  upon  the  question  of 
race  susceptibility.  It  is  sometimes  supposed  that  the  Latin 
races  are  the  most  susceptible  to  yellow  fever,  others  think  that 
the  black  races  are  immune.  As  a  matter  of  fact,  the  most 
recent  observations  prove  the  accuracy  of  the  old  writers  of 
authority  upon  yellow  fever. 

Writers  of  the  eighteenth  and  nineteenth  centuries  con- 
cluded that  no  race  was  exempt,  and  that  the  apparent 
exemption  of  the  black  races,  of  the  Creoles,  and  of  the 
Spanish-Indians,  would  readily  disappear  if  these  people  went 
to  Europe  for  a  long  stay.  Modern  observations  prove  that  all 
races  are  susceptible,  provided  they  come  from  climates  where 
yellow  fever  does  not  exist.  That  in  fact  it  is  entirely  a  question 
of  immunity} 

Those  living  and  born  in  a  country  where  disease  is  endemic, 
at  a  very  early  period  in  their  life  get  an  attack  of  the  disease, 
which  naturally  confers  a  certain  degree  of  immunity ;  later 
they  may  get  subsequent  attacks,  but  each  successive  attack  is 
less  serious ;  when  manhood  is  reached  the  subject  is  in  all 
probability  completely  immune.  This  was  the  case  in  Cuba, 
Vera  Cruz,  Rio,  Santos,  Para,  New  Orleans,  etc. 

It  is  this  fact  which  explains  why  yellow  fever  has  always 
been  regarded  as  a  disease  of  newcomers ;  it  does  not  matter  in 
the   very   least   whether    the    newcomers    are    Scandinavians, 

1  Findings    of   the    American-Cuban,    French,   German,   and    English 
yellow  fever  commissions. 

252 


4500 
4  400 
4300 
1200 
4100 

4000 

3900 
3800 
3700 
3600 
3500 
3400 
3300 
3200 
3100 
3000 
2900 
2800 
2700 
2600 
2S00 
2400 

| 

— 

— 

— 

| 

Brazilians 
foreigners 

2200 
2100 
2000 
1900 
1800 
1700 
1600 

I 

1 

1400 

1300 

1200 

1100 

1000 

900 

800 

700 

600 

500 

400 

300 

200 

150 

100 

50 



— 

: 

1 

1 

1 

B 

r-i 

1 

I 

1 

\ 

J 

1 

B 

1 

:.i 

1 

± 

Cases  of 

Yt"oV-fa*r 

1890 

1891 

1892 

1893 

1894 

1895 

1696 

1897- 

1898 

1899 

1900 

1901 

1902 

1903 

Fig,  33. — Table  prepared  by  Otto  &  Neumann  to  show  the  mortality  fiom  yellow  fever 
from  1890-1903,  that  is  the  period  of  active  anti-Stegomyia  measures.  The 
striking  feature  of  the  table  is  the  remarkable  disproportion  of  the  death-rates 
amongst  the  newcomers  (Foreigners)  and  the  inhabitants  (Brazilians).  The  table 
demonstrates  the  comparative  immunity  of  the  inhabitant. 


[Tojacep.  252. 


YELLOW  FEVER  IN  THE  BLACK  RACE    253 

British,  Latins,  Syrians,  Mohammedans,  Russians,  Indians, 
"  yellow  skins,"  blacks  or  whites,  the  question  alone  is  :  Are  they 
newcomers  or  not?  Have  they  resided  for  a  long  term  of 
years  in  a  country  where  there  is  no  yellow  fever  ? 

It  is  an  old  observation  that  those  blacks  and  "  yellow  skins  " 
who  resided  in  yellow  fever  free  districts  suffered  from  yellow 
fever  when  they  reached  a  town  where  it  was  prevalent.  During 
the  great  yellow  fever  epidemic  in  Philadelphia,  blacks  and 
whites  were  equally  affected,  and  there  are  numerous  other 
examples  to  the  same  effect. 

The  Creoles  who  leave  the  West  Indies  to  be  educated  in 
Europe,  or  the  Central  Americans  who  left  Vera  Cruz  or  other 
endemic  foci  for  a  few  years,  return  as  non-immunes  and  are 
liable  to  yellow  fever. 

It  is  an  old  and  often  repeated  observation 1  that  the  blacks 
of  West  Africa  rarely,  in  comparison  with  the  whites,  get  yellow 
fever ;  this  has  been  amply  borne  out  by  the  outbreaks  of 
yellow  fever  in  West  Africa  this  year,  19 10,  and  in  all  previous 
years.  On  the  other  hand,  last  year,  1909,  during  the  yellow 
fever  epidemic  in  Barbados,  out  of  a  total  of  "86  cases,  54  occurred 
amongst  the  black  inhabitants.  Yet  these  same  blacks  were  the 
descendants  of  the  African  immunes.  They  had,  therefore,  in 
the  meantime  become  non-immune  and  susceptible,  owing  to  the 
fact  that  yellow  fever  had  ceased  to  be  endemic  in  Barbados. 

In  the  Martinique  epidemic  of  1909,  the  blacks  were  likewise 
attacked.  The  fact  that  the  poor  native  black  inhabitants  of 
Barbados  were  more  susceptible  even  than  the  whites,  proved, 
in  my  opinion,  that  yellow  fever  was  not  endemic. 

1  Hirsch  quotes  fifteen  authorities  to  show  that  yellow  fever,  although  it 
does  occur,  is  less  severe  and  is  rarer  in  the  pure  negro  than  in  the  whites. 
Nearly  every  writer  on  yellow  fever  has  drawn  attention  to  this  observation. 
Berenger-Feraud  describes  two  cases  in  negroes,  and  cites  four  other 
authorities.  Drs  Durham  and  Myers  also  described  cases  amongst  the 
negroes  in  Para.  In  the  preceding  chapters  I  have  also  recorded  cases 
amongst  the  pure  negro.  The  evidence,  therefore,  is  that  the  disease  does 
occur  amongst  them,  but  is  rare. 


254        RACE  SUSCEPTIBILITY  AND  IMMUNITY 

Similarly,  the  fact  that  the  black  races  in  West  Africa  do 
not  exhibit,  as  a  rule,  the  severe  yellow  fever  symptoms,  nor 
die  from  the  disease  like  the  whites,  is  proof,  in  my  opinion,  that 
they  suffer  from  a  mild  form  of  the  disease  which  confers 
subsequent  partial  immunity. 

We  know  positively 1  that  neither  their  colour  nor  their  race 
confers  absolute  immunity  to  yellow  fever,  and  that  they  are  as 
liable  as  the  white  European  to  become  infected,  provided  they 
have  lived  out  of  Africa  for  a  long  period. 

As  to  the  question  of  the  susceptibility  of  native  races  to 
yellow  fever,  this  is  a  matter  of  considerable  importance.  The 
following  memoranda  are  of  use  : — 

We  know  the  natives  of  Central  and  South  America  (Indian- 
Spanish  race  "  yellow  skins  ")  appear  to  be  non-immunes.  We 
know  that  they  have  perished  in  great  numbers  in  the  interior 
towns  in  Guatemala  and  Spanish  Honduras  in  1909,  and  in 
many  other  years.  On  the  other  hand,  we  possess  positive 
evidence  that  in  large  towns  like  Rio,  Santos,  Havanna,  Para, 
etc.,  the  indigenous  inhabitants  suffered  far  less  severely  from 
yellow  fever  than  foreigners.  The  figures  are  conclusive  upon 
this  point,  and  demonstrate  that  in  the  large  towns-  the 
indigenous  inhabitants  were  immunised  in  childhood  by  mild 
attacks  of  the  disease. 

There  is  also  evidence  based  upon  tradition  that  the  ancient 
Mexicans  suffered  severely  from  yellow  fever. 

We  know  that  the  Hindoo  race  is  non-immune.  A  state- 
ment is  made  on  the  authority  of  Hirsch  that  the  Chinese  in 
South  America  appeared  immune  to  yellow  fever.  With  regard 
to  the  negro  race  we  know  that  mulattoes,  quadroons,  and  other 
mixed  varieties  are  quite  as  susceptible  as  the  whites  to  yellow 
fever.  All  authorities  agree  that  the  pure  blooded  negro  can 
get  yellow  fever,  but  that  in  the  majority  of  cases  it  is  less  severe 
than  in  the  whites. 

In  other  words,  observers  agree  that  there  is  some  degree 
1  Blair,  Hirsch,  Chassaignac,  La  Roche,  and  others. 


YELLOW  FEVER  IN  THE  BLACK  RACE         255 

of  immunity  amongst  the  blacks  or  Spanish-Indians.  Scheube 
is  of  this  opinion,  and  so  were  the  older  observers  like  Blair. 
The  following  figures  given  by  Chassaignac  during  the  1905  1 
New  Orleans  epidemic  are  of  great  interest.     He  states  : — 

It  was  conclusively  shown  that  during  the  1905  epidemic, 
negroes  and  whites  were  equally  liable  to  contract  the  disease, 
but  that  the  former  had  it  in  a  particularly  mild  form.  The 
statistics  were  as  follows  : — 

In  one  series  of  observations  the  mortality  amongst 
90  white  cases  was  20  per  cent,  and  amongst  950  coloured 
cases,  1-2  per  cent.  In  a  second  series  of  observations  the 
mortality  amongst  80  cases  amongst  the  whites  was  again 
20  per  cent.,  and  amongst  247  coloured  cases,  3  per  cent.  In  a 
third  series  out  of  500  cases  amongst  the  whites  there  were 
5 1  deaths,  and  out  of  200  coloured  cases,  1  death. 

Chassaignac  adds  that  the  evidence  is  of  the  greatest  import- 
ance, because  it  shows  that  the  blacks  are  equally  susceptible 
with  the  whites,  but  that  they  get  the  disease  in  a  remarkably 
mild  form,  which  can  be  readily  overlooked. 

La  Roche  states  that  in  Jamaica  the  mortality  rate  for  the  white 
troops  was  102  per  thousand,  and  for  the  black  soldiers,  8  per 
thousand.  In  the  Bahamas  the  rate  amongst  the  white  troops  was 
59  per  thousand,  and  amongst  the  blacks  5  to  6  per  thousand. 

These  observations  also  disprove  the  belief  that  blacks  are 
immune. 

Blair  states  that  out  of  1790  imported  blacks,  none  con- 
tracted yellow  fever  during  the  1852  epidemic. 

There  is  further  evidence  to  show  that  the  imported  negroes 
in  the  slave  days  did  not  get  the  disease  in  the  severe  form  in 
which  the  whites  did. 

If  we  examine  the  events  of  this  year,  19 10,  on  the  West 
Coast  of  Africa,  it  is  clear  that  the  blacks  did  not  suffer  in  the 
same  proportion  as  the  whites.    Taking  the  relative  proportion  of 

1  J.  Lazard  states  that  there  were  452  fatal  cases  amongst  the  whites  and 
6  amongst  the  negroes  in  the  1905  New  Orleans  epidemic. 


256        RACE  SUSCEPTIBILITY  AND  IMMUNITY 

the  whites  and  blacks  present  on  the  Gold  Coast  and  in  Sierra 
Leone  respectively,  there  is  a  relatively  very  high  case  and 
death-rate  amongst  the  white  population,  and  an  exceedingly 
small  one  amongst  the  black  population. 

The  older  observers  on  the  West  African  Coast,  like  Staff- 
surgeons  Barry,  Fergusson,  and  many  others,  were  emphatic  that 
the  negroes  did  not  suffer  from  yellow  fever  to  anything  like  the 
same  degree  as  the  whites  in  the  various  epidemics  on  the  coast. 

On  the  other  hand,  as  previously  stated,  we  know  that  the 
present-day  descendant  of  the  West  African  native,  as  he  is 
met  with  in  Barbados,  is  not  immune  ;  we  know  that  the  same 
descendant  serving  in  the  West  African  regiment  in  the  barracks 
at  Freetown  is  not  immune,  and  that  from  time  to  time  in  the 
various  epidemics,  cases  and  deaths  have  occurred. 

These  apparently  conflicting  observations  can,  in  my  opinion, 
be  explained  only  upon  the  ground  of  acquired  immunity.  The 
West  African  negro  has  an  acquired  immunity,  and  the  evidence 
is  in  favour  of  his  having  been  in  this  position  in  slave  days,  just 
as  I  believe  he  is  to-day. 

Therefore  slaves  exported  from  West  Africa  and  newly 
arrived  in  the  States  or  in  the  West  Indies  were  to  a  certain 
degree  protected  by  previous  attacks  in  childhood,  and  did  not 
suffer  like  the  other  races.  When,  however,  new  generations  of 
negroes  had  grown  up  under  the  new  conditions  in  Barbados  or 
elsewhere,  where  there  was  considerable  or  complete  protection 
from  the  Stegomyia  owing  to  its  smaller  numbers  or  complete 
absence,  they  naturally  became  non-immune.  They  no  longer 
got  the  mild  attacks  that  their  ancestors  were  accustomed  to 
suffer  from,  either  in  Africa  or  during  transport  on  the  old-time 
slave-ships. 

The  evidence,  in  my  opinion,  points  strongly,  not  only  to 
yellow  fever  being  endemic  on  the  West  African  Coast,  but  that 
the  home  of  yellow  fever  may  be,  after  all,  West  Africa,  and  not 
the  New  World. 

Whether  the  immunity  just  described  is  inherited  in    any 


«  ACCLIMATISATION  " 


257 


degree,  it  is  very  hard  to  decide.  If  there  is  an  inherited 
immunity,  it  is  soon  lost  as  demonstrated  above ;  and  the 
immunity  as  it  exists  in  the  African  negro  to-day  can  be 
explained  by  his  having  acquired  this  immunity  by  inoculation. 

Vice  versa,  it  is  a  well-known  and  often  proved  observation 
that  those  whites  who,  being  born  in  yellow  fever  countries, 
survive  childhood,  grow  up  to  be  resistant  to  yellow  fever.  The  old 
physicians  said  that  they  became  acclimatised,  whilst  Creoles 
who  left  for  a  long  stay  in  Europe  became  de-acclimatised. 

We  now  know,  thanks  to  the  experimental  observations  of 
the  American,  Cuban,  French,  and  Brazilian  observers,  that 
acclimatisation  means  becoming  infected  by  the  Stegomyia  with 
a  mild  attack  of  yellow  fever  which  confers  partial  immunity. 
The  word  "  acclimatisation  "  of  the  eighteenth  and  nineteenth 
centuries  means  "  immunisation  "  to-day. 

The  most  striking  figures  showing  the  effects  of  local 
immunisation  is  furnished  by  the  mortality  tables  of  Rio  since 
the  year  1890.  A  glance  at  this  table  shows  that  the  mortality 
amongst  new  arrivals  was  ten  to  eighteen  times  greater  than 
amongst  the  natives  of  Rio.  A  more  conclusive  demonstration 
of  immunity  through  previous  attacks  could  not  be  furnished, 
and  it  finds  its  exact  parallel  to-day  in  the  history  of 
yellow  fever  in  Africa.     The  figures  for  Rio  are : — 


Year. 

Brazilians. 

Foreigners. 

1890 

76 

636 

1891 

249 

4083 

1892 

374 

3716 

1893 

43 

777 

1894 

384 

4372 

1895 

64 

754 

1896 

304 

2599 

1897 

15 

141 

1898 

no 

955 

1899 

86 

639 

1900 

39 

303 

1901 

79 

220 

1902 

201 

777 

1903 

188 

376 

258        RACE  SUSCEPTIBILITY  AND  IMMUNITY 

Since  the  general  application  of  2.nt\- Stegomyia  measures  in 
Rio,  the  enormous  difference  between  the  death-rate  amongst 
Brazilians  and  foreigners  has  appreciably  decreased,  and  no 
doubt  will  disappear,  owing  to  the  fact  that  all  the  inhabitants 
are  rapidly  becoming  non-immunes.  Applying  this  reasoning 
to  West  Africa,  we  know  that  outbreaks  of  yellow  fever  have 
been  far  more  frequent  than  is  usually  supposed  during  the  last 
hundred  years. 

We  know  that  in  this  year,  1910,  yellow  fever  broke  out 
independently  at  four  separate  points  in  British  Colonies,  viz., 
Freetown,  Secondee,  Axim,  and  Saw  Mills. 

We  know  that  inquiry  on  the  spot  failed  to  prove 
importation.  We  are  forced  therefore  to  conclude  that  the 
disease  was,  to  use  the  phraseology  of  the  older  observers  on  the 
coast,  a  product  of  the  place  itself.  In  other  words,  that  the 
disease  was  endemic. 

If,  then,  the  disease  is  endemic — a  view  which  is  held  by  some 
British,  German,  and  French  authorities,  who  have  investigated 
the  disease  upon  the  spot — it  remains  to  ask :  By  whom  is  the 
virus  of  yellow  fever  maintained  ? 

From  whom  do  the  Stegomyia  derive  their  infection  ?  The 
answer  to  this  can  only  be  the  black  races ;  we  know  that  the 
whites  are  not  immunised  in  sufficient  numbers.  On  the  other 
hand,  we  know  that  the  black  races  are  very  considerably 
immunised,  or  how  otherwise  would  they  escape  yellow  fever  ? 
Then  it  is  to  the  black  races  that  we  must  look  for  the  source  of 
supply  of  the  yellow  fever  virus  ;  it  is  they  who,  in  childhood  and 
adolescence,  have  the  disease  in  a  mild  form  :  but  mild  though  it 
be,  quite  sufficient  to  infect  the  Stegomyia,  as  the  inoculation 
experiments  of  the  American  Commission  proved.  In  other 
words,  the  black  natives  have  the  so-called  mild  or  ambulatory 
form  of  yellow  fever. 

These  mild  forms  pass  unrecognised  amongst  the  natives 
just  as  the  sister  disease — malaria — does,  but,  nevertheless,  like 
malaria,  it  is  there. 


Cases 

of 
Yellow 
Fever. 


32 
31 
30 
29 
28 
27 
26 
25 
24 
23 
22 
21 
20 
19 
18 
17 
16 
15 
14 
13 
/2 
II 
10 
9 
8 
7 
6 
5 
4 
3 
2 
I 


263 


1825 


1829 


1859 


106         1100 


/845 


1859 


|  ~~1=  Whites 

=  Nafive  Negros 

^West  Indian  Soldiers 


1866 


/87Z 


1884 


cq 


lil 


pq 


1890 


1900 


Fig.  3+.— Diagram  showing  some  of  the  outbreaks  of  yellow  fever  in  West  Africa 
from  1825-1910.  Until  1884  there  is  no  record  of  deaths  from  Yellow  Fever 
amongst  the  black  natives.  From  1884  note  the  marked  disproportion  between 
the  white  and  black  death-rate. 


[To  face  p.  258. 


NEW  ARRIVALS  AND  YELLOW  FEVER         259 

From  analysis  of  all  the  facts  I  can  come  to  no  other  con- 
clusion than  that  a  very  large  proportion  of  the  "  remittent " 
and  "  bilious  remittent "  fevers  of  West  Africa  to-day  are 
the  well-known  mild  forms  of  yellow  fever.  The  African 
native  is  as  saturated  with  yellow  fever  as  he  is  with 
malaria,  and  his  escape  from  severe  yellow  fever,  and  its 
very  frequent  occurrence  amongst  the  whites,  is  proof  of  this 
contention. 

But,  it  may  be  argued  by  some,  if  yellow  fever  has  been 
endemic  in  Africa  so  long,  how  comes  it  that  all  the  whites  have 
not  perished  ? 

As  a  matter  of  fact  the  death-rate  from  diagnosed  yellow 
fever  has  been  exceedingly  high ;  in  the  second  place  there  is 
no  doubt  whatever  that  a  vast  amount  of  yellow  fever  has 
passed  unrecognised  amongst  the  whites ;  in  the  third  place 
European  whites  have  during  the  last  decade  taken  measures 
which,  without  their  being  aware  of  it,  protected  them.  They 
have  lived  to  a  certain  extent  segregated  in  larger  and  better 
houses,  and  the  use  of  the  mosquito  net  is  now  very  general. 
Both  these  measures  afforded  a  very  great  degree  of  protection. 
It  is  well  known  to  students  of  yellow  fever,  the  remark- 
able comparative  immunity  which  even  partial  segregation 
gives.  Were  this  not  a  well-recognised  rule  in  connection 
with  all  infectious  diseases,  mankind  would  have  long  since 
disappeared. 

The  final  proof  that  remittent  and  bilious  remittent  fevers 
are  in  a  large  number  of  instances  the  mild  forms  of  yellow 
fever,  will  be  given  when  by  the  destruction  of  the  Stegomyia  in 
West  Africa,  these  fevers  will,  if  my  reasoning  be  correct, 
disappear  in  great  part  with  yellow  fever,  precisely  as  they  have 
done  from  Barbados,  Rio,  and  from  ships,  from  the  Southern 
States  of  America,  and  from  Spain. 

Liability  of  new  arrivals  to  yellow  fever. — It  is  surprising  how 
few  people  stop  to  consider  what  is  the  significance  of  the 
remarkable  proneness  of  new  arrivals  to  yellow  fever.     This  is 


260        RACE  SUSCEPTIBILITY  AND  IMMUNITY 

nevertheless  one  of  the  oldest  and  best  authenticated  observa- 
tions in  connection  with  the  disease. 

In  Health  Progress  and  Administration  in  the  West 
Indies,  I  have  drawn  frequent  attention  to  it  and  given  the 
statistics  of  the  mortality  rate.  The  older  observers  summed  up 
the  liability  of  new  arrivals,  by  stating  that  the  lower  the 
temperature  of  the  country  in  which  the  newcomer  had  resided, 
the  greater  was  the  liability  to  yellow  fever.  Blair  gives  the 
following  two  tables  : — 


Mortality  Incidence  according  to   Race. 


No. 

Nationality. 

Percentage. 

I 
2 

3 
4 

5 

West  Indian  Islanders 

French  and  Italians  .... 

English,  Irish,  and  Scotch 

German  and  Dutch   .... 

Swedes,  Norwegians,  and  Russians  . 

6.9 
17.1 
19-3 

20-0 
27-7 

This  race  proportion,  although  it  has  not  to  do  with  the 
temperature  of  the  native  country  of  the  arrivals,  nevertheless 
may  be  brought  about  by  the  fact  that  the  inhabitants  of  the 
West  Indies  were  no  doubt  considerably  immunised  before  they 
arrived  in  British  Guiana.  In  the  same  way  the  French  and 
Italians  might  have  come  from  South  America  and  the  West 
Indies,  in  both  of  which  places  they  would  have  been  liable  to 
attacks  of  yellow  fever.  The  evidence  is  overwhelming  that 
race  does  not  confer  complete  immunity.  In  the  1905  New 
Orleans  yellow  fever  epidemic,  yellow  fever  was  most  prevalent 
and  severe  amongst  the  Sicilian  workmen,  who  formed  a  large 
proportion  of  the  labouring  population  of  the  city,  and  who 
were  for  the  most  part  new  arrivals ;  but  in  the  previous 
epidemics  when  the  labouring  population  was  chiefly  new 
arrivals  from  Ireland,  these  were  most  affected.  It  was  again 
the  question  of  non-immunes.  The  following  useful  table  of 
Blair's  shows  the  mortality  rate  amongst  new  arrivals : — 


NEW  ARRIVALS  AND  YELLOW  FEVER 


261 


Table  of  489   Cases  of  Yellow  Fever  admitted  into  the 
Seamarfs  Hospital,  Demerara. 


Time  in  Harbour. 

Total  Cases. 

Deaths. 

Percentage. 

Under  1  week 

19 

I 

5'2 

I  to     2  weeks     . 

84 

17 

20-2 

2   „     4      ,, 

137 

38 

27-7 

4  „     6      „         •        • 

98 

31 

31-6 

6   „     9      „ 

96 

34 

35-4 

9   „    12      „ 

32 

5 

15-6 

12   „   16      ,, 

17 

1 

5-8 

16  upwards  . 

6 

2 

33-3 

References 
Hirsch  (A.) — Geographical  and  Historical  Pathology,  London,  1883. 
Veitch — A  Letter  to  the  Commissioner  for  Transports  on   Yellow  Fever, 

London,  18 18. 
Blair    (D.) — Some  Account  of  the    Yellow  Fever  Epidemic   of  British 

Guiana,  London,  1850. 
Chassaignac  (G.) — "  Prognoses  of  Yellow  Fever,"   in  Augustin's   History 

of  Yellow  Fever,  New  Orleans,  1909. 
Reports  by  Staff-surgeons  Barry  and  Fergusson,  MS.  Reports,  Freetown. 
Boyce  (Sir   R.  W.)— Health  Progress  and  Administration  in  the    West 

Indies,  Barbados,  London,  1909. 
Scheube  (B.) — Die  krankheiten  d.  Warmer  Lander,  Jena,  1900. 
Brady  (C.  M.) — "The  Prevalence  and  Diagnosis  of  Yellow  Fever  in  the 

Coloured   Race,"   Read  before  the   New    Orleans   Parish    Medical 

Society,  nth  November  1905. 
Durham    (H.    E.) — Report  of  the     Yellow    Fever  Expedition  to  Para, 

Liverpool  School  of  Tropical  Medicine,  1902. 
Marchoux,  Salimbeni,  et  Simond  — "  La  fievre  jaune,"  Rapport  de  la 

Mission  francaise  Annates  de  VInstitut  Pasteur,  1903 -1906. 


PART    V 

ENTOMOLOGY 

For  much  practical  assistance  in  the  preparation  of  this  chapter, 
I  am  indebted  to  my  friend  and  colleague,  Prof.  Newstead ; 
and  for  permission  to  reprint  the  section  dealing  with  the 
Stegomyia  in  West  Africa,  I  am  indebted  to  the  courtesy 
of  Dr  Guy  Marshall,  Secretary  of  the  Entomological 
Research  Committee. 


26S 


.«  "S 


CHAPTER   XVII 

GEOGRAPHICAL   DISTRIBUTION    OF   THE   STEGOMYIA    CALOPUS 

It  will  be  seen  from  the  following  summary  and  from  the 
chart,  that  the  distribution  of  this  mosquito  is  widespread  over 
the  tropical  regions  of  the  globe. 

In  Central  America,  in  the  West  Indies,  in  the  Gulf  Ports  of 
the  United  States,  in  South  America,  and  in  West  Africa,  a 
large  number  of  investigations  have  been  made  which  show  that 
the  mosquito  was,  or  is,  exceedingly  abundant  in  these  parts. 
On  the  other  hand,  less  is  known  of  the  relative  abundance  of  the 
Stegomyia  in  the  eastern  ports  and  in  Australasia,  although  the 
presence  of  the  mosquito  has  been  noted. 

Since  1899,  the  period  of  the  organised  attack  upon  yellow 
fever,  the  abundance  of  the  Stegomyia  has  been  substantially 
reduced  in  very  many  places,  notably  in  the  Gulf  Ports,  Central 
America,  the  West  Indies,  and  in  parts  of  Brazil. 

Moreover,  improved  sanitary  control  of  towns  and  the  intro- 
duction of  pipe-borne  water  have  also  slowly  brought  about  a 
great  reduction  in  the  number  of  breeding-places  in  centres  of 
population.  So  much  so  has  the  reduction  taken  place  that  to 
this  alone  can  be  ascribed  the  disappearance  of  endemic  yellow 
fever  from  towns  like  New  Orleans,  Panama,  Vera  Cruz,  Rio, 
and  Santos,  and  from  many  of  the  West  Indies. 

There  is  no  doubt  that  a  very  large  volume  of  Stegomyia  is 
necessary  to  keep  up  endemicity.  This  fact  has  been  pointed 
out   by  Gorgas   and   by   other  observers,   and   from    my  own 

265 


266     DISTRIBUTION  OF  THE  STEGOMYIA  CALOPUS 

investigations  in  the  West  Indies,  in  Central  America,  and  in 
West  Africa,  I  have  come  to  the  same  conclusion. 

I  have  pointed  out  in  Health  Progress  and  Administration  in 
the  West  Indies,  the  remarkable  contrast  of  fifty  years  ago  with 
the  state  of  affairs  to-day,  as  regards  yellow  fever  in  the  West 
Indies ;  formerly,  almost  every  new  arrival  became  infected 
with  yellow  fever ;  to-day  this  does  not  occur,  and  the  West 
Indies  are  regarded  rightly  as  pleasure  and  health  resorts. 

The  only  way  in  which  it  is  possible  to  explain  this  extra- 
ordinary diminution  in  the  disease  is  by  the  equally  great  dimi- 
nution in  the  numbers  of  the  carrier  of  the  disease,  the  Stegomyia. 
There  can  be  no  doubt  that  this  insect  has  been  in  places 
enormously  reduced  in  numbers.  The  reduction  has  therefore 
led  to  the  interruption  of  continuous  yellow  fever  infection,  such 
as  is  necessary  to  maintain  an  endemic  state. 

From  time  to  time,  however,  small  outbreaks  of  yellow  fever 
occur,  as  last  year,  1909,  for  example,  in  Barbados. 

These  are  explained  by  the  persistence  of  localised  foci  in 
certain  towns  of  the  Stegomyia  in  very  large  numbers.  When, 
therefore,  a  case  of  yellow  fever  is  introduced  from  some 
country  where  it  is  still  endemic,  it  lights  up  a  small  localised 
outbreak  confined  strictly  to  the  particular  Stegomyia  area.  If 
the  infected  Stegomyia  and  the  larvae  are  killed  in  such  an 
area,  yellow  fever  stops  in  a  few  weeks  and  cannot  progress. 

Considerations  like  these  make  it  of  the  greatest  practical 
importance  to  ascertain  in  all  localities,  whether  the  Stegomyia 
is  present  in  sufficient  numbers  to  keep  up  endemic  yellow  fever, 
or  only  to  maintain  an  outbreak  or  a  few  cases,  were  the  disease 
imported. 

For  this  reason,  I  make  it  a  rule  to  make  house  to  house 
examinations,  in  order  to  arrive  at  an  accurate  percentage 
distribution  of  the  Stegomyia. 

I  assume  that  if  every  house  and  yard  is  breeding  the 
Stegomyia,  that  is,  if  the  Stegomyia  is  present  in  a  town  to  the 
extent  of  100  per  cent,  that  in  all  probability  yellow  fever  is 


SUMMARY  267 

endemic.  If,  on  the  other  hand,  the  percentage  is  only  10  per 
cent.,  then  the  disease  is  not  endemic.  Of  course,  in  many 
towns  the  percentage  distribution  is  not  by  any  means  uniform. 
For  example,  in  one  particular,  poor,  neglected,  and  over- 
crowded quarter  in  a  town  or  village,  the  Stegomyia  may  be 
present  to  the  extent  of  ioo  per  cent.,  whilst  in  the  suburbs  the 
percentage  may  be  less  than  5. 

In  such  a  case  as  this,  it  is  possible  for  yellow  fever  to 
become  epidemic  and  to  remain  endemic  in  the  former  quarter, 
whilst  in  the  5  per  cent,  area  only  a  few  sporadic  cases  may  be 
recorded.  In  the  history  of  yellow  fever  in  North  America,  in 
Europe,  and  recently  in  the  West  Indies,  this  striking  relation- 
ship of  yellow  fever  to  the  number  of  Stegomyia  has  been  over 
and  over  again  noted. 

Further  information  upon  these  points  will  be  found  in  my 
British  Honduranian  and  Central  American  Report  on  yellow 
fever,  and  more  recently  in  my  investigations  in  the  West 
Indies  recorded  in  Health  Progress  and  Administration  in  the 
West  Indies. 

I.— Summary  of  the  Geographical  Distribution  of 
THE  Stegomyia  calopus. 

AFRICA. — British  East  Africa,  Mombassa ;  Natal,  Durban  ; 
Egypt,  Cairo,  Ismailia,  Khartoum,  Nile  generally ;  Senegal, 
Senegambia,  Sierra  Leone,  Gold  Coast,  Togoland,  Dahomey, 
Nigeria;  Mashonaland ;  Mauritius,  Port  Louis,  common 
near  shore,  scarcer  in  high  parts ;  Fernando  Po,  Cape  Verd 
Islands ;  Portuguese  East  Africa,  Delagoa  Bay ;  Seychelles, 
Victoria  ;   Transvaal,  Komatipoort ;  Zanzibar,  Nairobi. 

AMERICA  (NORTH). — Lower  California;  United  States:  "In 
considerable  numbers  in  the  Southern  United  States  and 
as  far  north  on  the  Atlantic  coast  as  Virginia "  (Howard). 
Alabama,  Arkansas,  Florida,  Georgia,  Illinois,  Indiana, 
Kentucky,     Louisiana,    Maryland,    Mississippi,    Missouri, 


268     DISTRIBUTION  OF  THE  STEGOMYIA  GALOP  US 

North  Carolina,  Savannah,  South  Carolina,  Tennessee, 
Texas. 

AMERICA  (South).— Brazil,  Manaos,  Para,  Iquitos,  etc.,  Rio  de 
Janeiro,  etc. ;  British,  French,  and  Dutch  Guiana,  Venezuela  ; 
Chili,  Valparaiso ;  Ecuador,  Colombia,  Guayaquil ;  Peru, 
Callao. 

America  (Central)  (along  the  Atlantic  coast-line).— 
British  Honduras,  Belize,  Cuba,  Puerto  Cortez ;  Costa  Rica, 
Limon,  Bocas  del  Toro ;  Guatemala,  Livingston,  Puerto 
Barrios ;  Mexico,  Acapulco,  Carmen,  Champoton,  Ciudad 
Victoria,  Coatzocoalcos,  Cordoba,  Cozumel,  Frontera, 
Juanajuata,  La  Paz,  Las  Penas,  Linares,  Mazatlan,  Merida, 
Monterey,  Nantla,  Orizaba,  Pachuca,  Perihucte,  Pochutla, 
Progresso,  Rincon,  Antonio,  Salina  Cruz,  Saltillo,  San  Bias, 
Tampico,  Tepic,  Tlacotalpam,  Tonala,  Tuxpan,  Vera  Cruz ; 
Nicaragua,  Bluefields  ;  Panama,  Ancon,  Colon,  Culebra. 

West  Indies  and  the  Bahama  Islands. — Barbados, 
Bermuda,  Cuba,  Dominica,  Grenada,  Jamaica,  Nassau, 
Nevis,  Porto  Rico,  San  Salvador,  St  Kitts,  St  Lucia,  St 
Vincent,  Trinidad. 

ASIA  (including  East  Indies). — Andaman  Islands ;  Arabia, 
Port  Said,  Muscat;  Assam,  Lushai  Hills;  Burmah  ; 
Celebes;  Cochin  China,  Hatien,  Tonkin;  India,  Rhim  Tal, 
Calcutta,  Ceylon,  Ferozepore,  Kumaon,  Lucknow,  Madras, 
Purneah  Quilon,  Travancore ;  Japan,  Tokyo ;  Java, 
Batavia,  Garvet,  Samarany,  Soekaboemi;  Malaya,  Perak, 
Singapore;  New  Guinea;  Palestine;  Philippines,  Luzon, 
Mindano,  Panay  ;  Siam,  Phrapatoon. 

Australia  (including  Oceania) — Fiji  Islands;  Hawaian 
Islands,  Hilo,  Honolulu;  New  South  Wales;  Pitcairn 
Islands  ;  Queensland,  Bupengang  ;  Samoa,  Apia  ;  Solomon 
Islands  ;  South  Australia,  Port  Darwin  ;    Victoria. 

EUROPE. — Cyprus,  Larnaka;  Greece,  Poros;  Italy;  Malta 
(reported  19 10);  Portugal,  South  Portugal;  Spain,  Dol ; 
Gibraltar,  Malaga. 


BREEDING-PLACES  269 

II. — Investigation  of  Breeding-Places 

I  have  learnt,  as  the  result  of  long  experience,  that  the  only 
sure  way  to  arrive  at  a  correct  estimation  of  the  number  and 
kinds  of  mosquitos  present  in  a  town,  is  to  make  a  systematic 
house  to  house  inspection  of  all  articles  containing  water. 

For  this  purpose,  it  is  necessary  to  have  a  block-  or  house- 
plan  of  the  town,  and  to  divide  the  town  up  into  sections,  and 
then  to  work  over  each  section  house  by  house. 

In  specially  printed  note-books,  divided  into  columns  for 
cisterns,  tanks,  barrels,  tubs,  wells,  kerosene  tins,  "  odds  and  ends," 
broken  crockery,  bottles,  and  "  other  receptacles "  (as  flower 
vases,  lily  tubs,  etc.,  etc.),  the  number  of  water-containers  found 
is  systematically  entered,  and  a  note  made  as  to  whether 
Stegomyia  larvae  are  present  or  absent. 

When  I  and  my  assistants  (usually  the  sanitary  inspectors) 
have  made  our  survey,  all  the  odds  and  ends  and  discarded  tins 
are  collected  together  and  brought  out  into  the  street  for  the 
dust  cart  to  remove  ;  if  larvse  are  found  in  barrels  or  cisterns,  the 
water  is  emptied,  or  if  that  is  impracticable,  kerosene  oil  is 
poured  in ;  the  occupier  of  the  house  is  admonished  and 
reasoned  with,  and  the  sanitory  inspector  enters  the  name  and 
address  of  the  offender  in  his  book,  and  if  the  nuisance  occurs 
again,  action  is  taken.  In  order  to  discover  all  the  discarded 
tins,  etc.,  it  is  very  often  necessary  to  get  the  wild  bush  in  the 
compound  cleared ;  and  this  invariably  discloses  a  large 
number  of  receptacles  containing  stagnant  water  and  harbour- 
ing innumerable  larvae. 

In  addition  to  the  examination  of  the  yard,  the  interior  of 
the  house  must  not  be  overlooked,  for  it  is  quite  a  common 
occurrence  to  find  the  larvae  of  Stegomyia  in  collections  of 
water  allowed  to  remain  stagnant  in  the  house ;  for  example,  in 
flower-vases,  saucers  of  flower-pots,  glasses  employed  for  striking 
cuttings  of  the  croton  plant,  water  ewers,  indoor  water  cisterns, 
fire   buckets,  etc.     I    have  found  the  larvse  on  more  than  one 


270     DISTRIBUTION  OF  THE  STEGOMYIA  CALOPUS 

occasion   in   the  water  used  for  cooling  the  irons  in  a  black- 
smith's shop. 

The  abundance  or  otherwise  of  the  Stegomyia  may  be 
influenced  by  the  nature  of  the  occupation  of  the  towns-people. 
In  a  fishing  village,  or  where  canoes  are  abundant,  enormous 
numbers  of  larvae  are  frequently  harboured  in  the  rain-water 
which  collects  in  the  canoes.  If  there  is  much  cooperage,  rain- 
water often  collects  on  the  upturned  bottoms  of  the  barrels, 
and  harbours  larvae ;  in  some  villages,  conch  or  snail  shells  are 
abundant,  and  these  contain  larvae ;  in  other  places  calabashes 
or  cocoanut  husks  abound.  In  Belize,  British  Honduras,  I 
found  vast  numbers  of  larvae  in  the  irregular  depressions  and 
forks  in  the  logs  of  logwood  piled  up  on  the  wharf  ready  for  the 
steamer ;  the  purple,  almost  black-coloured  water  in  the  holes 
did  not  in  the  least  affect  the  larvae.  Then  again,  every  country 
has  its  own  special  receptacles  liable  to  contain  larvae.  In 
Louisiana,  Central  and  South  America,  the  large  wooden  rain- 
water vats  are  the  common  offenders.  In  many  of  the  West 
Indies  large  stoneware  jars  (olive  jars)  create  a  nuisance.  In 
Trinidad  the  "  antiformicas "  placed  around  flower-beds  to 
protect  the  flowers  from  the  attacks  of  the  umbrella  ant 
usually  harbour  larvae.  In  Freetown,  the  habit  of  making 
"  ornamental "  borders  to  flower-beds  by  sinking  into  the  earth 
a  row  of  inverted  bottles  is  a  fertile  source  of  Stegomyia ;  the 
cup-shaped  depression  at  the  bottom  of  the  bottles  holds 
water,  and  in  these  the  Stegomyia  deposits  her  eggs.  Imper- 
fectly broken  glass  on  walls  is  another  source.  Rot-holes  of 
all  kinds  in  trees,  the  axils  of  the  Aroideae,  of  the  Traveller's 
Palm,  and  of  many  other  plants,  form  receptacles  which  may 
prove  a  nuisance.  I  have  found  larvae  breeding  in  the  puddles 
formed  on  the  flat  mud  roofs  of  houses  in  Cape  Coast  Castle. 
The  roof-gutters  of  houses  are  common  receptacles.  Less 
frequent  breeding-places  are  marsh-holes,  puddles,  and  drains. 
I  have  found  Stegomyia  larvae  in  all  these  latter  places,  but  in 
my  opinion,  less  frequently.     In  my  experience,  this  mosquito 


FlG.  38. — A  Sama  Tree,   with  Epiphytes,   which  hold  water  and 
Siegomvia  larvae. 


[To  face  p.  270. 


BREEDING-PLACES  271 

most  frequently  selects,  for  breeding  purposes,  wooden 
receptacles  of  all  kinds,  especially  barrels  in  which  there  is  a 
thin  coating  of  minute  green  algae ;  next  in  frequency,  all  small 
collections  of  water  in  tins  and  cans  of  every  description,  when 
protected  by  the  shade  of  foliage  from  the  sun's  rays  and  the 
heavy  rains.  In  West  Africa  I  have  not  met  with  epiphytes 
growing  in  any  abundance  upon  the  trees ;  indeed  the  Brom- 
eliaceae  are  conspicuous  by  their  absence.  In  the  West  Indies 
the  reverse  is  the  case.  When  they  are  present  they  collectively 
hold  a  large  quantity  of  water  and  support  a  very  large  number 
of  larvae. 

As  the  investigator  gains  experience,  two  facts  begin  to 
strike  him.  Firstly,  the  very  small  quantity  of  water,  from  a 
teaspoonful  upwards,  which  will  suffice  as  a  breeding-place  for 
the  Stegomyia  ;  and  on  this  account,  the  smallest  odds  and  ends 
which  may  contain  water  should  be  examined.  Secondly,  the 
immense  number  of  discarded-  empty  sardine  tins,  milk  tins, 
meat  tins,  and  tin  cases  of  all  kinds,  which  are  to  be  found  in 
all  towns  opening  up  to  commerce.  A  veritable  tin  can 
invasion  extends  up  from  the  coast  towns  into  the  interior 
villages.  The  more  traders,  the  more  tin  cans ;  the  nearer  the 
more  primitive  villages  are  approached,  the  less  become  the 
white  traders,  and  the  less,  in  consequence,  the  number  of 
discarded  tins.  In  other  words,  tinned  foods  of  all  kinds,  oil 
tins  and  tin  packing  cases  are  most  abundant  where  there  are 
white  settlers  and  traders.  This  has  brought  about  a  condition 
which  immensely  favours  the  development  of  the  Stegomyia. 
The  total  water-holding  capacity  of  these  discarded  tins  is  very 
great  indeed,  vastly  greater  than  the  inexperienced  would  at  first 
sight  suppose.  For  the  tins  are  not  always  obvious  when  you 
enter  a  compound  ;  the  fact  being  that  the  larger  number  are 
concealed  amongst  the  weeds  and  low  bush  which  invariably  is 
present  in  the  majority  of  compounds,  and  on  waste  places  in 
and  immediately  around  towns  and  villages  on  the  banks  of 
rivers  and  streams,  and  along  the  seashore.     These  receptacles 


272     DISTRIBUTION  OF  THE  STEGOMYIA  CALOPUS 

becoming  filled  by  the  first  shower  of  rain,  and  being  to  a  great 
extent  protected  from  the  sun's  rays  by  the  overhanging  grass 
and  leaves,  the  water  does  not  evaporate,  and  ideal  breeding- 
places  are  thus  afforded  for  the  Stegomyia.  To  sum  up,  the 
breeding-places  of  the  Stegomyia  are  almost  exclusively  artificial, 
including  all  receptacles  in  which  by  accident  or  design,  water 
is  stored,  and  not  repeatedly  renewed.  It  is  for  this  reason  that 
all  anti-mosquito  by-laws  must  be  specifically  directed  against 
stagnant  water,  which,  in  the  tropics,  has  been  rightly  termed 
"  the  great  enemy  of  mankind." 

Stegomyia  fasciata  is  usually  regarded  as  a  clean-water 
breeder,  and  so  it  is  for  the  most  part ;  occasionally,  however, 
it  will  be  found  in  very  dirty  water,  in  company  with  the  larvae 
of  various  species  of  Culex  and  Chironomus.  I  have  sometimes 
met  with  it  in  drains  and  marsh-pools  in  the  vicinity  of  houses. 

The  striking  feature  about  the  Stegomyia,  as  Beauperthuy 
long  ago  recognised,  and  one  which  every  investigator  soon 
appreciates,  is  its  essentially  domestic  nature.  It  is  the  true 
house-haunting  mosquito  of  the  tropics,  and  like  the  cat  and  dog 
is  never  far  from  the  abode  of  man.  I  have  never  seen  them  in 
swamps,  far  away  from  human  habitations. 

These  features  in  the  life-history  of  the  Stegomyia  render  it 
easily  amenable  to  control,  or  even  extirpation.  It  is  for  that 
reason  that  it  is  very  essential  in  every  town  to  make  a  precise 
survey  to  ascertain  where  the  Stegomyia  is  breeding. 

III.— Stegomyia  SURVEYS 

To  arrive  at  an  accurate  percentage  in  making  a  Stegomyia 
survey,  I  adopt  either  the  house  or  the  compound  as  the  unit. 
In  some  countries  it  is  very  easy  to  make  the  house  and  its 
yard  the  unit.  In  less  advanced  countries  the  towns  and 
villages  are  divided  up  into  compounds  or  lots,  and  in  each  of 
these  there  may  be  two,  four,  or  six  houses.  Therefore,  if  the 
"  lot "  or  "  compound "   is   taken   as   the   unit,  the   number   of 


CHARACTERISTICS  OF  THE  STEGOMYIA         273 

houses  in  each  should  be  recorded  where  possible,  but  it  is  not 
always  easy. 

In  examining  a  house  and  its  attached  yard,  the  probability 
will  be  that  the  larvae  of  the  Stegomyia  will  be  found  in  several 
receptacles.  I  make  a  record  of  this  in  my  note-book,  as  it 
bears  upon  the  question  of  the  total  numbers  of  the  mosquito ; 
but  for  calculating  the  percentage  I  regard  it  simply  as  one 
house  in  which  the  Stegomyia  is  present.  In  the  case  of  a 
compound  or  yard  containing  more  than  one  house,  if  I  find 
receptacles  in  that  yard  harbouring  larvae,  I  assume  that  all  the 
houses  are  infected,  as  they  are  equally  exposed  to  the 
Stegomyia. 

The  aim  and  object  of  the  survey  is  to  ascertain  the  number 
of  houses  in  a  town  or  village  in  which,  or  immediately 
around  which,  Stegomyia  are  breeding,  and  which,  therefore,  are 
infested  with  the  mosquito.  I  have  worked  out  these  per- 
centages for  a  great  number  of  the  larger  towns  in  the  West 
Indies  and  British  Guiana,  and  also  in  British  Honduras,  and  I 
am  of  opinion  that  they  give  a  very  fair  idea  of  the  distribution 
of  the  Stegomyia. 

The  size  of  the  vessel  in  which  the  larvae  are  found  only 
affects  the  question  of  the  total  number  of  the  insects.  The 
presence  of  only  two  larvae  in  a  teaspoonful  of  water,  contained 
perhaps  in  a  snail  shell  or  the  broken  end  of  a  bottle  fastened 
into  a  wall,  is  not  less  significant  than  the  presence  of  hundreds 
of  larvae  in  a  barrel ;  for  it  shows  how  ubiquitous  that  particular 
mosquito  must  be. 

IV. — Some  Characteristics  of  the  Stegomyia  and  its 

Larvae 

Having  now  had  several  years'  experience  of  this  mosquito, 
I  record  here  those  features  which  appear  to  me  to  be  most 
characteristic.  The  most  salient  point  is  the  essentially 
domestic   instinct   of  this  mosquito,  which  is,  above  all  others, 

s 


274    DISTRIBUTION  OF  THE  STEGOMYIA  C  J  LOP  US 

the  most  "  house-haunting "  species.  I  have  never  found  it 
breeding  far  from  the  abode  of  man,  not  more  than,  say,  50  to 
100  yards.1  It  is  fond  of  dark  situations,  breeding  preferably 
in  shaded  barrels  and  odd  receptacles.  Therefore  a  most 
favourite  site  is  any  water  vessel,  such  as  a  jar  or  barrel 
stowed  away  in  a  corner  in  the  kitchen,  or  in  a  bedroom. 

The  mosquito  avoids  windy  places,  and  therefore  selects  not 
only  quiet  stagnant  water,  but  places  where  the  air  is  stagnant. 
As  soon  as  the  imago  emerges  from  the  pupa,  it  makes  for  the 
dark  places  in  the  house.  It  alights  preferably  on  dark  or  black 
material.  So  far  as  I  have  been  able  to  judge,  I  do  not  think 
that  it  flies  any  great  distance  at  one  time,  although  of  course 
its  travelling  may  be  very  greatly  assisted  by  the  cover  of  trees 
or  a  long  line  of  huts,  which  would  enable  it  to  progress  from 
point  to  point  sheltered  from  wind  and  rain.  Some  observers 
give  100  yards  as  its  maximum  distance  of  flight.  Whatever 
this  may  be,  however,  I  consider  that  it  may  safely  be  said  that 
this  mosquito  does  not,  as  a  rule,  fly  long  distances.  It  seeks 
cover  as  soon  as  it  emerges  from  the  pupa,  but  it  may  travel 
from  house  to  house,  and  is  certainly  capable  of  entering  ships 
moored  in  rivers.  In  conformity  with  its  house-haunting 
domestic  nature  is  the  fact  that  it  is  probably  the  most  common 
mosquito  found  on  ships ;  numerous  observations  in  recent 
years,  and  the  endless  records  of  yellow  fever  on  board  ship  in 
the  nineteenth  century,  amply  testify  to  this  fact.  Given 
the  suitable  conditions  of  freedom  from  draughts,  darkness,  and 
warmth,  it  can  remain  secreted  for  weeks  in  the  holds,  galleys, 
engine  rooms,  or  bunks  of  a  ship.  It  is  for  this  reason  that  it  is 
so  essential  to  screen  ships  which  trade  in  rivers  in  yellow  fever 
countries,  or  to  insist  that  they  shall  be  moored  several  hundred 
yards  from  shore. 

With  regard  to  the  appearance  of  the  mosquito  itself,  it  is 
very   readily   recognised.     On   the    wing,   it    appears   grey   in 

1  Bouffard  places  the  distance  limit  at  100  metres ;  Le  Moal  gives  it  as 
250  metres. 


FlG.   39. — "Wiggle  Waggle,"  or  Larva  of 

Stegomyia  fasciata   (magnified    about    6  times). 

(After  Newstead.) 


FlG.  40. — Stegomyia  fasciata,  F.   (  =  ca/of>//s,  Mg.)    9, 
the  mosquito  which  carries  yellow  fever. 

(After  Newstead.)  [To  face  p.  274. 


CHARACTERISTICS  275 

colour,  and  it  glides  from  point  to  point  just  like  a  small  bit  of 
"  fluff."  On  account  of  its  colour  and  markings,  it  is  known  as 
the  "Scots  Grey,"  or  the  "'Tiger'  mosquito."  When  it  alights, 
the  two  long  banded  white  hind  legs  continually  waving  up  and 
down  are  very  characteristic. 

As  I  have  said  above,  this  species  is  usually,  though  by  no 
means  always,  a  clean-water  breeder  ;  this  habit  is  doubtless  due 
to  the  fact  that,  being  essentially  a  house-frequenting  mosquito, 
it  naturally  seeks  out  the  water  nearest  at  hand,  and  this  is,  of 
course,  the  domestic  drinking,  cooking,  and  washing  supply.  It 
has  therefore  come  to  be  known  as  a  clean-water  breeder;  so 
much  so,  that  its  presence  in  water  is  taken  as  evidence  of  the 
good  quality  of  the  latter.  From  this  belief  has  sprung  a 
further  deduction,  namely,  that  the  presence  of  the  larvae  in 
water  is  beneficial ;  for  it  is  supposed  that  they  feed  on  harmful 
bacteria,  and  therefore  tend  to  purify  the  water.  I  have  made 
experiments  to  determine  whether  there  is  any  truth  in  this 
belief,  and  I  have  found,  as  indeed  might  be  expected,  that  the 
contrary  is  the  case,  and  that  water  containing  larvae  becomes 
much  more  crowded  with  bacteria  than  water  without  larvae.1 
The  natural  food  of  the  larvae  appears  to  consist  of  minute 
algae. 

Stegomyia  fasciata  bites  in  the  daytime  as  well  as  at  night,2 
and  in  my  experience  it  is  noiseless.  When  it  has  bitten  a 
person  suffering  from  yellow  fever  in  the  infectious  stage,  the 
virus,  whatever  its  nature,  requires  twelve  to  thirteen  days  to 
mature  in  the  body  of  the  mosquito  before  the  latter  is  capable 
of  transmitting  the  infection.  This  period  is  known  as  the 
"  extrinsic  incubation  period."  When  once  the  mosquito  is 
infected,  all  evidence  points  to  the  fact  that  it  retains  the 
infection  for  a  very  long  period ;  three  months  has  been  noted, 

1  "The  Effect  of  Mosquito  Larvae  upon  Drinking  Water,"  Boyce  and 
Lewis,  Annals  of  Tropical  Medicine  and  Parasitology,  March  1910. 

2  Goeldi  (Os  Mosquitos  no  Para,  p.  103)  states  that  S.  fasciata,  in  Para 
bites  persistently  by  day,  and  that  while  it  does  bite  also  at  night,  such  cases 
are  certainly  exceptional. 


276     DISTRIBUTION  OF  THE  STEGOMYIA  C A  LOP  US 

but  it  is  quite  possible  that  the  infection  lasts  as  long  as  the  life 
of  the  mosquito.  It  is  precisely  because  of  the  length  of 
duration  of  the  infection  in  the  Stegomyia  that  it  is  possible  to 
explain  the  well-known  sporadic  outbreaks  of  cases  of  yellow 
fever  which  frequently  occur  long  after  an  epidemic  is  supposed 
to  have  disappeared.  There  is  no  conclusive  evidence  that  the 
infected  female  Stegomyia  transmits  the  virus  to  its  eggs  and 
larvae. 

The  following  entomological  notes  have  been  kindly 
furnished  by  Mr  Newstead : — 

V. — Differential  Diagnosis  of  Stegomyia  fasciata,  with 
Descriptions  of  two  nearly  Allied  Species.  (By 
R.  Newstead,  M.Sc.) 

Stegomyia  fasciata t,  F. 

General  characters  as  seen  with  a  pocket  lens,  X  16: — Head 
dark,  with  a  distinct  double  white  median  line  and  with  white 
lines  laterally  and  round  the  eyes ;  palpi  black,  white  at  the 
tip ;  proboscis  black.  Thorax  brown,  with  two  brilliant  silvery 
broad  lateral  curved  lines,  which  converge  from  in  front  towards 
the  middle  of  the  thorax,  these  becoming  much  narrower  and 
continuing  parallel  to  one  another  as  far  as  the  scutellum  ;  in 
the  middle  there  are  two  parallel  yellowish  or  whitish  lines 
running  the  whole  length  of  the  thorax.  Scutellum  very 
marked,  owing  to  its  being  completely  covered  with  silvery 
white  scales.  Plurae  with  several  patches  of  brilliant  white 
scales.  Abdomen  dark,  with  white  bands  on  the  bases  of  the 
segments.  Legs  black,  the  femora  for  the  most  part  pale 
beneath,  in  many  cases  with  a  distinct  white  line  running  from 
the  base  almost  to  the  apex  and  situated  on  the  inner  surface, 
a  white  spot  is  also  visible  at  the  apex ;  tibiae  black ;  the  first 
and  second  pair  of  legs  with  two  white  bands  on  the  tarsi,  the 
hind  pair  with  five  white  bands,  the  last  joint  being  wholly 
white. 


DIFFERENTIAL  DIAGNOSIS  277 

Wings  with  the  veins  darkly  scaled,  the  upper  fork  cell  being 
distinctly  longer  than  the  second  and  its  base  slightly  nearer 
the  root  of  the  wing. 

Length  3-5  to  5  mm. ;  the  average  length  is  about  4-5  mm.,  but 
very  small  specimens  are  often  met  with. 

The  following  descriptions  of  two  closely  allied  species  of 
mosquitos  may  assist  the  student  in  determining  Stegomyia 
calopus : — 

Stegomyia  (Scutomyid)  sugens,  Wiedemann 

Characters  as  seen  wider  a  lens,  x  16: — Head  black,  with  a 
thin  median  whitish  line  and  a  white  patch  on  each  side ;  palpi 
black,  white  at  tip ;  proboscis  black.  Thorax  dark  brown  with 
several  scattered  whitish  scales  giving,  under  the  hand-lens,  the 
appearance  of  a  fairly  distinct  broad  median  pale  line;  there 
are  also  pale  areas  laterally.  On  the  anterior  portion  may  also 
be  seen  four  silvery  white  spots,  two  on  each  side  and  somewhat 
widely  separated.  Scutellum  white ;  pleurae  with  patches  of 
white.  Abdomen  deep  black,  with  white  bands  on  the 
bases  of  the  segments.  Legs  black ;  the  femora  with  a  white 
spot  at  the  apex  and  a  distinct  white  ring  a  short  distance  from  it, 
rather  pale  ventrally.  The  tibiae  of  the  fore  and  mid  legs  with  a 
somewhat  indistinct  white  band  towards  the  basal  half,  those  of 
the  hind  pair  with  a  very  marked  band  near  the  centre?-  The  tarsi 
of  the  first  two  pairs  with  three  narrow  white  bands,  those  of  the 
last  pair  with  five  broad  bands,  the  last  joint  being  all  white. 

Wings  with  the  veins  darkly  scaled,  the  first  fork  cell  being 
longer  than  the  second,  their  bases  being  almost  level. 

Length  4  to  5-5  mm. 

Stegomyia  (Kingia)  africana,  Theobald 

Characters  as  seen  under  a  lens,  x  16: — Head  black,  with  a 
yellowish   spot   in    the   middle ;    proboscis   black ;    palpi   black, 

1  According  to  Theobald  {Mon,  Culicid.  i.,  p.  301),  this  tibial  band  is  not 
present  in  all  specimens. 


278     DISTRIBUTION  OF  THE  STEGOMYIA  C A  LOP  US 

with  the  tips  white.  Thorax  black,  with  two  short  glittering 
lines  directed  upwards  on  the  anterior  part,  and  a  similar  small 
spot  at  the  base  of  each  wing ;  scutellum  white ;  pleurae  with 
several  silvery  spots.  Abdomen  dark  brown,  unbanded,  with 
pale  rather  indistinct  lateral  spots  on  some  of  the  last  segments. 
The  last  segment  with  two  bright  metallic  spots ;  venter 
with  bands  of  the  same  metallic  appearance  as  those  on 
the  thorax.  Legs  black ;  femora  with  metallic  white  patches 
on  the  inner  surface ;  tibiae  of  the  first  two  pairs  of  legs 
black,  of  the  hind  pair  with  a  white  basal  band,  narrow  on 
the  upper  surface  but  much  deeper  on  the  ventral  surface. 
Tarsi  of  the  fore  and  mid  legs  with  two  rather  indistinct  white 
bands  ;  hind  pair  with  four  bands,  the  third  being  very  broad, 
and  the  fourth  narrow.  The  two  latter  are  separated  by  a 
small  black  band. 

Wings  similar  to  Stegomyia  fasciata. 

Length  4  to  4-5  mm. 

The   following    synopsis    may    also    assist    the    student    in 
discriminating  these  three  species  : — 


Stegomyia  fasciata. 

Stegomyia  sitgens. 

Stegomyia  africana. 

Head     .     . 

Distinct    double    me- 
dian   and    marginal 
lines. 

Indistinct   white    me- 
dian line  and  lateral 
white  patches. 

Yellowish  spot  in 
centre. 

Thorax .     . 

Dark  brown,  with  two 
narrow       yellowish- 
white  parallel  median 
lines  and  two  silvery 
lateral   curved  lines 
(Lyre-pattern). 

Dark  brown,  with  four 
silvery   white    spots 
on  the  anterior  part, 
and  pale  areas  due 
to  scattered   silvery 
scales 

Black,  with  two  short 
white  metallic  lines 
directed  upwards  on 
the  anterior  portion, 
and  a  spot  of  similar 
appearance  at  the 
base  of  each  wing. 

Abdomen  . 

Dark,  with  white  basal 
bands     and     lateral 
spots. 

Dark     brown,    with 
white    basal     bands 
and  lateral  spots. 

Dark  unbanded,  with 
pale  rather  indistinct 
lateral  spots  on  some 
of  the  last  segments. 
The  last  segment 
with  two  bright  me- 
tallic spots. 

EGGS  AND  LARVAE 


279 


Stegomyiafasciata. 

Stegomyia  sugens. 

Stegomyia  africana. 

Legs      .    . 
Legs      .    . 

Femora  often  with  a 
distinct    white    line 
continuing  from  the 
base   almost  to   the 
apex  ;    white  apical 
spot ;  pale  ventrally. 
Tibiae  black. 

Tarsi  of  fore  and  mid 
pairs   of    legs   with 
two    white     bands  , 
hind   pair  with   five 
bands,  the  last  joint 
being  all  white. 

Femora  with  a  white 
ring   near  the  apex 
and   a  white   apical 
spot;  scattered  white 
scales   ventrally. 
Tibiae  with  a  white 
band    near    middle, 
more  distinct  in  the 
hind  pair. 

Tarsi  of  fore  and  mid 
pairs   of    legs    with 
three   narrow   white 
bands ;     hind      pair 
with    five    broad 
bands,*  last  joint  all 
white. 

Femora  with  metallic 
patches  on  the  inner 
surface.      Tibiae    of 
fore   and    mid    legs 
black,   of   hind   pair 
with    a   white   basal 
band  much  broader 
on  the  ventral  sur- 
face. 

Tarsi  of  fore  and  mid 
pairs  with  two  indis- 
tinct  white    bands  ; 
hind  pair  with  four 
bands,  the  third  very 
broad,  and  the  fourth 
very  small. 

*  These  are  deeper  than  those  in  Stegomyia  fasciata. 


VI. — Characteristics  of  the  Egg  and  Adult  Larva  of 

Stegomyia  fasciata 

The  egg. — This  is  very  elongate,  blackish  in  colour  and 
rather  sparsely  studded  with  minute  white  hemispherical  bodies 
of  whitish  secretionary  matter. 

The  larva. — One  of  the  marked  habits  of  the  larva  is  that 
it  occasionally  swims  and  wriggles  along  the  surface  of  the 
water  like  the  larvae  of  certain  Anophelines.  It  has  been  shown 
(see  p.  282)  that  it  is  capable  of  remaining  submerged  for 
relatively  longer  periods  than  is  commonly  the  case  among 
the  larvae  of  numerous  other  Culicines. 

The  siphon  is  about  one-fourth  of  the  entire  length  of  the 
abdomen,  and  about  two  and  a  half  times  longer  than  the 
width  at  the  base.  This  character  is,  however,  not  altogether 
reliable,  as  the  larvae  of  other  Culicines  possess  siphon  tubes  of 
similar  dimensions. 

The  distinguishing  morphological  characters,  which  can 
only  be  determined  by  the  aid  of  the  microscope,  are  as 
follows : — 

Antennae  smooth,  the  tuft  being  represented  by   a   single 


280    DISTRIBUTION  OF  THE  STEGOMYIA  CALOPUS 

short  hair ;  at  the  apex  there  is  a  minute  but  distinct  second 
joint  and  a  few  very  delicate  hairs  (figs.  I  and  2).  The  labial 
plate  possesses  eleven  to  twelve  teeth  on  each  side  and  a  larger 
terminal  one ;  the  base  is  also  symmetrically  crenulated  as 
shown  (fig.  3).  The  thorax  is  rather  hairy,  some  of  the  hairs 
arising  from  four  distinct  chitinous  hooks  (fig.  4)  situated  two 
on  each  side  of  the  thorax.  On  the  eighth  segment  of  the 
abdomen  are  the  lateral  combs ;  each  of  these  is  composed  of 
from  eight  to  ten  serrated  spines,  varying  in  form  and  also  in 
the  number  of  serrations  (figs.  5  and  6).  The  siphon  or  pecten 
spines  (figs.  7  and  8)  are  variable  in  form  and  number,  there 
being  in  the  specimen  under  observation  twelve ;  immediately 
following  there  is  a  triple  hair.  The  last  segment  is  very  short, 
being  almost  rectangular  and  bears  a  number  of  bifurcated 
hairs 1  (fig.  9) ;  the  papillae  are  stout,  about  one  and  a  half 
times  the  length  of  the  segment  and  with  rounded  ends. 

VII.— On  the  Life-Cycle  and  Larval  Habits  of 

THE   STEGOMYIA 

Period  of  the  life-cycle. — For  information  on  this  subject  we 
have  to  rely  chiefly  upon  the  evidence  which  has  been  adduced 
by  Goeldi  {Os  Mosquitos  no  Para).  It  must  be  noted,  how- 
ever, that  climatic  conditions  have  a  marked  influence  on  the 
developmental  cycle  of  this  insect  in  any  given  locality,  and  it 
may  be  taken  as  a  general  rule  that  cold  will  retard  any  one  of 
the  stages  either  of  the  ova,  larvae,  or  pupse ;  while  a  rise  in 
temperature  will  so  shorten  the  cycle  as  to  bring  it  within  the 
shortest  period  possible. 

The  egg. — Under  normal  conditions  the  incubation  period 
in  the  Amazon  region  has  been  found  to  vary  from  three  to 
eight  days ;  the  average,  however,  may  be  taken  as  three  to 
four  days. 

Larval  stage. — The  minimum   period,  as  given  by  Francis 

1  These  are  not  simple  as  stated  and  figured  by  Wesche  {Bull.  Entom. 
Research,  April  19 10,  p.  25). 


H.  F.  Carter  ad  nat.  del. 

FlG.  41. — Characteristics  of  the  larva  of  Stegomyia  fasciata. 

6.  Serrated   spine   from  side  of  lateral 
comb. 

7.  Pecten  spine  from  base  of  siphon. 

8.  Pecten  spine,  situated  near  the  apex 
of  the  siphon. 

9.  Bifurcated  hair  from  the  ninth  abdo- 
minal segment. 


1.  Apex  of  antenna. 

2.  Antenna,  showing  the  tuft,  composed 

of  a  single  hair. 

3.  Labial  plate. 

4.  Thoracic  hook. 

5.  Serrated  spine  from  centre  of  lateral 

comb. 


[To  face  p.  280. 


LIFE  CYCLES  281 

(Publ.  Health  and  Mar.  Hosp.  Serv.  Rep.,  xxii.,  1907,  p.  382),  in 
water  kept  at  an  even  temperature  of  8o°  F.,  was  seven  days.  In 
Newstead's  record  {Journ.  Trop.  Med.  and  Paras,  Liverpool,  iv., 
p.  143)  nine  days  are  given,  and  the  temperature  that  of  230  C. 
(  =  73-4°  F.).  Mitchell x  states  that  the  larval  stage  extends  over 
a  period  of  from  eight  to  thirteen  days  "  in  fairly  warm  weather." 

Pupal  stage. — The  duration  of  this  stage  varies  from  one  to 
five  days.  Mitchell  (loc.  at.)  gives  one  to  five  days ;  Newstead 
two  to  three  days  in  a  temperature  of  230  C. 

Adults. — The  female  lays  her  eggs  in  from  six  to  fifteen 
days  after  taking  the  first  meal  of  blood,  but  Mitchell  (loc.  cit.,  p. 
148)  states  that  the  female  may  feed  two  or  three  times  before 
laying  the  first  batch  of  eggs.  The  average  number  of  separate 
batches  of  eggs  laid  by  a  single  female  may  be  given  as  two  to 
three ;  but  as  many  as  nine  batches  have  been  laid  in  some 
cases. 

The  eggs  are  extruded  singly,  and  the  number  laid  on  each 
occasion  varies  from  twenty-seven  to  ninety-seven.  Goeldi2 
found  that  as  a  rule  the  females  died  immediately  after  the 
final  act  of  parturition,  though  in  two  instances  females 
survived  for  twelve  and  fourteen  days  respectively.  He  also 
states  that  fertilised  ova  may  lie  latent  in  the  body  of  the 
parent  for  from  twenty-three  to  one  hundred  and  two  days,  and 
that  the  female  may  lay  her  eggs  at  the  end  of  these  periods, 
respectively,  after  taking  a  meal  of  blood.  It  is  evident, 
therefore,  that  ovulation  is  retarded  until  suitable  food  is 
obtained. 

It  is  generally  held  that  the  females  feed  almost  exclusively 
upon  warm-blooded  vertebrates,  and  it  is  usually  supposed  that 
such  food  is  necessary  for  the  development  of  fertile  eggs. 
Goeldi  succeeded,  however,  in  inducing  females  to  feed  upon 
honey,  a  diet  upon  which  they  survived  for  periods  varying 
from  thirty-one  days  to,  in  one  instance,  one  hundred  and  two 

1  Mosquito  Life,  p.  148,  1907. 

2  Os  Mosquitos  no  Para. 


282     DISTRIBUTION  OF  THE  STEGOMYIA  CALOPUS 

days,  though  it  is  evident  that  such  food  has  a  retarding  or 
neutral  effect  upon  ovulation. 

Males  of  Stegomyia  fasciata  also  survived  on  honey  for 
periods  varying  from  twenty-eight  to  seventy-two  days. 

These  important  data  point  to  the  fact  that  in  a  state  of 
nature,  both  sexes  may,  as  occasion  serves,  feed  upon  the  nectar 
of  flowers,  though  one  has  failed  to  find,  in  the  innumerable 
publications  which  have  been  issued  regarding  the  habits  of 
this  insect,  any  evidence  that  this  actually  takes  place  under 
natural  conditions. 

Food  of  the  larvce} — So  far  as  one  can  gather  there  is  no 
evidence  as  to  the  exact  nature  of  the  food  of  the  larvae.  In 
captivity  they  feed  largely  upon  amorphous  matter  and  upon 
the  macerated  remains  of  minute  crustaceans  {Cyclops  sp., 
Diaptomus  sp.,  etc.),  minute  fragments  of  aquatic  plants,  and 
occasional  diatom  and  unicellular  plants. 

The  larvae  of  Stegomyia  fasciata  have  been  found  in  associa- 
tion with  those  of  several  other  species  of  mosquitos,  notably 
with  those  of  Culex  fatigans  and  to  a  less  extent  with  Limatus 
durhami,  etc.  Dupree  has  made  some  interesting  discoveries 
regarding  the  habits  of  the  larvae,  which  are  communicated  by 
Mitchell  in  her  excellent  memoir  (Joe.  at.,  p.  147).  It  is  stated  that 
the  young  larvse  are  remarkably  tenacious  of  life  under  water  ; 
they  tolerated  as  much  as  three  hours'  submergence,  and  in  some 
cases  were  resuscitated  after  five  hours ;  on  the  other  hand, 
adult  larvae  tolerated  total  immersion  for  one  and  a  half  to 
two  hours.  This  habit  enables  them  to  feed  at  the  bottom  of 
cisterns  of  normal  depth  and  to  remain  submerged  for  unusually 
long  periods. 

Resistance  to  frost. — There  is  apparently  no  direct  evidence 

to  prove  that  the  larvae  of  Stegomyia  fasciata  can  survive  at  a 

temperature  of  freezing  point,  although  they  have  been  found 

1  Boyce  (R.)  and  Lewis  (F.)— "  Effect  of  Mosquito  Larvae  upon  Drinking 
Water,"  Annals  of  Trop.  Med.  and  Parasit.,  vol.  iii.,  1910.  Experiments 
were  made  to  determine  whether  larvae  fed  upon  and  removed  bacteria  in 
water.     The  conclusions  arrived  at  were  that  the  bacteria  were  increased. 


RESISTANCE  OF  THE  OVA  283 

by  Francis  {loc.  ct't.)  at  Mobile,  Ala.,  U.S.A.,  living  in  tubs  placed 
in  sheltered  positions  during  frosty  weather,  and  when  the  water 
in  vessels  exposed  to  the  open  air  was  coated  with  ice  half  an 
inch  thick.  But  it  is  noteworthy  that  some  large  healthy  larvae, 
which  were  found  in  the  living-room  of  a  hospital,  died  when 
placed  in  an  ice-box  where  the  temperature  was  about  500.  It 
is  quite  evident,  however,  that  this  insect  can  survive  at  a 
relatively  low  temperature,  as  may  be  gathered  from  the  state- 
ments given  by  Mitchell,1  who  says  that  larvae  were  found  by 
her  in  November  at  Baton  Rouge  at  a  temperature  as  low  as 
340  F. ;  and  further  that  pupation  took  place  in  water  at  530  F. 
Cold  "  stiffens "  the  adults,  but  one  was  observed  by  her  to 
revive  afterwards. 


VIII. — Viability  of  the  Ova  after  long  Exposure 
to  Dry  Atmospheric  Conditions 

Mr  F.  V.  Theobald 2  was  apparently  the  first  to  discover 
that  the  eggs  of  this  mosquito  will  remain  fertile  for  a  long 
period,  although  exposed  to  normally  dry  atmospheric  conditions. 
In  this  instance  the  eggs  were  forwarded  to  England  from  Cuba 
in  a  perfectly  dry  test-tube.  After  a  period  of  two  months 
they  were  placed  in  "  tepid  water,"  and  the  majority  of  them 
produced  larvae.  Many  of  these  larvae  survived  until  the  tenth 
day,  and  six  of  them  pupated  at  the  end  of  three  weeks,  one  of 
which  gave  rise  to  a  perfectly  well-formed  female.  Unfortun- 
ately no  details  are  given  as  to  the  temperature  in  which  this 
experiment  was  conducted  ;  but  it  is  important  to  note  that 
the  insects  were  reared  in  a  greenhouse. 

Newstead  3  has  conducted  similar  experiments  with  eggs  of 
this  mosquito  from  material  forwarded  from  Manaos  by  Dr  H. 
Wolferstan  Thomas  in  the  year  1906.  The  eggs  were  laid  on 
moist  white  filter-paper ;  these  were  dried  in  the  air  and  sub- 

1  Mosquito  Life,  p.  148,  1907.  2  Mon.  Culicida:,  vol.  iii.,  p.  143. 

3  Joum,  Trop.  Med.  and  Parasitology,  Liverpool,  vol.  iv.,  p.  143. 


284    DISTRIBUTION  OF  THE  STEGOMYIA  CALOPUS 

sequently  placed  in  a  desiccator  with  chloride  of  calcium  for 
twenty-four  hours,  and  finally  transmitted  to  England  in  glass 
tubes,  tightly  corked.  The  following  data  indicate  the  results 
of  this  experiment: — 

September  9  to  n.     Eggs  laid  at  Manaos,  Amazon. 
October    26  Eggs    reached    England.    Placed    in    water  at    a 

temperature  of  23°  C.  (  =  73-4°  F.). 
„         27  Twelve  larvae  hatched  during  the  previous  night  and 

one  after  twelve  hours'  immersion. 
„  28  Larvae  began  moulting. 

„  30  All  larvae  completed  first  moult. 

November  4  Larvae  pupated. 

„  7  First  imago,  a  male,  hatched.     This  example  lived 

for  six  days. 
„  8  A  male  and  female  hatched. 

The  breeding-jar  was  kept  in  an  incubator  at  an  even 
temperature  of  230  C.  For  the  greater  part  of  the  time  the 
insects  were  in  complete  darkness ;  but  a  little  light  was 
admitted  occasionally  during  the  day. 

Summary 
Eggs  remained  dormant  and  practically  dry  45  to  47  days. 

Life-cycle 

Eggs.     Incubation  period        .        .        .        .  6  to  12  hours. 

Larval  stage 9  days. 

Pupal  stage 3  days. 

Complete  cycle 12  to  13  days. 

From  these  data  it  will  be  seen  that  the  life-cycle  was 
completed  as  rapidly  as  the  minimum  period  given  by  Goeldi x 
in  his  classical  memoir  on  the  mosquitos  of  Para.  This  is  all 
the  more  remarkable  seeing  that  the  larvae  and  pupae  were  kept 
in  almost  total  darkness,  and  also  in  a  highly  vitiated  atmosphere. 
Subsequent  experiments  have  proved,  however,  that  eggs  kept 
for  a  longer  period  than  two  years  lose  their  vitality  and  become 
completely  desiccated.     Surgeon  Francis  has  also  shown  that 

1  Os  Mosquitos  no  Para^  p.  6. 


RESISTANCE  OF  THE  OVA  AND  LARV.E        285 

eggs  "  may  remain  viable  for  six  and  a  half  months  when  kept 
dry."  It  should  be  noted,  however,  that  in  this  instance  the 
eggs  were  not  artificially  dried,  as  was  the  case  with  those 
which  were  forwarded  to  Liverpool  from  Manaos,  but  were 
allowed  to  remain  attached  to  the  sides  of  the  jar  in  which  they 
were  laid,  above  the  level  of  the  water,  and  "set  aside  in  a 
wardrobe  in  a  room  which  had  no  fire  in  it  all  winter,  and  the 
doors  and  windows  were  open  night  and  day."  The  tempera- 
ture in  which  these  eggs  were  kept  is  omitted  also  in  this  case. 
At  the  end  of  the  period  stated  above,  eggs  placed  in  a 
temperature  of  8o°  F.  produced  larvae  six  days  after  the 
parent  insects  had  emerged  from  the  pupae.  The  complete 
cycle  in  this  case  was  shorter  by  about  two  days,  than  that 
obtained  by  Goeldi  in  a  tropical  climate  and  apparently  under 
normal  conditions. 

Peryassu  has  also  succeeded  in  rearing  larvae  from  eggs 
which  had  been  exposed  to  dry  atmospheric  conditions  for  a 
period  of  five  months  ;  and  adds  that  "this  was  the  maximum 
time  they  resisted,  and  after  this  they  did  not  hatch." 

Boyce  brought  specimens  of  larvae  alive  to  Liverpool,  which 
were  collected  in  Puerto  Barrios  in  Guatemala  on  26th  October. 
They  were  kept  in  a  test-tube  exposed  to  the  great  variations 
of  temperature  which  occurred  in  travelling  from  Guatemala  to 
New  Orleans,  New  Orleans  via  Washington  to  New  York,  and 
then  across  the  Atlantic  to  Liverpool.  The  journey  occupied 
twenty-five  days. 

References 

Boyce  (Sir  R.  W.) — Report  to  the  Government  of  British  Honduras  upon 
the  Outbreak  of  Yellow  Fever  in  1905,  London,  1906. 
Yellow  Fever  Prophylaxis  in  New  Orleans,  1905,  Memoir  XIX.,  Liverpool 

School  of  Tropical  Medicine,  1906. 
Health  Progress  and  Administration  in  the  West  Indies  (2nd  edition) 

London,  19 10. 
"The   Prevalence,    Distribution,   and   Significance  of  the   Stegomyia  in 
West  Africa,"  Bulletin  of  Entomological  Research,  December  1910. 
GORGAS  (W.  C.)— "  Method  of  the  Spread  of  Yellow  Fever,"  Proc.  Canal 
Zone  Med.  Association,  1908. 


286     DISTRIBUTION  OF  THE  STEGOMYIA  CALOPUS 

Theobald  (W.  T.) — A  Mo?iograf>h  of  the  Culicidce,  London,  1901. 
Public  Health  and  Mar.  Hosp.  Ser.  Rep.  No.  14,  vol.  xxii.,  1907. 
Os  Cullicideos  do  Brazil,  p.  373,  1908. 
Marchoux  (E.),  Salimbeni  (A.),  et  Simond  (P.  L.) — "La  fievre  jaune," 

Rapport  de  la  Mission  francaise  Ann.  I nstitut  Pasteur,  1903. 
GRUBBS   (S.    B.)— "A    Note    on    Mosquitos    in    Baggage,"   Yellow    Fever 
Institute,  Bulleti?i  No.  6,  1902. 


Bale.  JtJ>anielS30n.L '" 


CHAPTER   XVIII 

DISTRIBUTION    OF   THE   STEGOMYIA    IN    AFRICA 

Stegomyia  calopus,  according  to  Otto  and  Neumann,  has  been 
long  known  in  the  Senegambia,  Sierra  Leone,  and  Slave  Coast, 
and  in  other  parts  of  the  West  Coast  of  Africa.  There  can  be 
no  doubt  that  the  species  has  been  present  certainly  through 
the  eighteenth  and  nineteenth  centuries,  that  is  to  say  during 
the  period  of  recorded  outbreaks  of  yellow  fever.  Whether  it 
was  originally  introduced  into  the  West  Coast,  or  whether,  like 
other  mosquitos,  it  is  an  original  native  of  the  coast,  it  is  quite 
impossible  to  be  certain,  seeing  that  we  know  so  little  of  the 
early  history  of  insect  life.  We  do  know,  however,  that  the 
Stegomyia  could  readily  have  been  introduced  by  any  ship,  from 
the  sixteenth  to  the  twentieth  century,  trading  between  yellow 
fever  countries  and  West  Africa.  But  the  reverse  could  equally 
well  have  taken  place,  and  indeed  some  authorities,  Goeldi  for 
example,  regard  the  West  Coast  as  an  original  home  of  the 
Stegomyia.  But  whatever  its  origin,  it  has  been  long  an  inhabi- 
tant of  the  West  Coast.  Evidence  is  in  favour  of  its  having 
greatly  multiplied  during  the  eighteenth  and  nineteenth 
centuries,  that  is  to  say,  during  the  period  of  the  opening  up  of 
the  coast  of  Africa  to  Western  civilisation.  As  soon  as  towns 
increased  in  size  and  new  ones  sprung  into  existence,  the 
Stegomyia  was  given  enormously  increased  opportunities  for 
breeding,  as  compared  with  the  primitive  periods.  No  doubt 
the  mosquito,  like  yellow  fever  itself,  increased  with  commercial 
development   until   comparatively    recently,  when,    thanks    to 

287 


288     DISTRIBUTION  OF  THE  STEGOMYIA  IN  AFRICA 

scientific  research,  steps  were  taken  to  wage  war  on  the 
breeding- places.  We  know  that  the  mosquito  is  present  in 
Togoland,  Dahomey,  Nigeria,  Gold  Coast,  the  Cameroons, 
Sierra  Leone,  Gambia,  and  Senegal.  It  has  also  been  recorded, 
so  it  is  stated,  in  German  and  British  East  Africa  and  in 
Durban. 

In  1901  Major  Ross,  and  in  1904  Dr  Prout,  drew  attention 
to  the  prevalence  of  Stegomyia  in  Freetown.  The  late  Dr 
Dutton  pointed  out  in  1902  that  this  mosquito  was  the  species 
most  commonly  met  with  in  Bathurst.  From  recent  observa- 
tions carried  out  by  Graham  and  others,  there  is  no  doubt  that 
Stegomyia  fasciata  is  to-day  the  common  mosquito  of  the  Coast 
towns. 

As  yellow  fever  has  again  this  year  (1910)  declared  itself 
both  on  the  Gold  Coast  and  in  Sierra  Leone,  it  is  now  a 
necessity,  before  it  is  too  late,  to  take  steps  to  ascertain  accur- 
ately the  prevalence  and  distribution  of  this  pest  all  over  Africa. 
Yellow  fever  has  penetrated  to  the  Sudan,  and  it  may  spread  to 
the  East  Coast  and  North  of  Africa,  if  not  already  there  in  an 
endemic  form. 

1.   The  "Stegomyia"  in  Sierra  Leone 

Freetown. — In  1901,  Ross  pointed  out  the  prevalence  of 
Stegomyia  fasciata,  and  organised  mosquito  brigades  to  do  away 
with  it  and  other  mosquitos.  Dr  Prout  also  drew  attention  to 
its  prevalence. 

This  year,  1910,  careful  surveys  have  been  made  both  by 
myself  and  Dr  Kennan  and  his  assistants,  with  the  following 
results  :— 

In  the  month  of  August  1910,  I  made,  with  Dr  Kennan,  the 
senior  sanitary  officer,  a  house  to  house  investigation  of  Free- 
town, and  covered  altogether  200  houses  with  their  yards  and 
out-houses. 

The  streets  selected  were  representative  of  the  various  classes 
in   Freetown,  including   the  merchants'  quarters,  those  of  the 


SIERRA  LEONE  AND  FREETOWN  289 

small  traders  and  Syrians,  and  the  native  residential  quarters 
of  the  well-to-do  and  the  poorest. 

The  200  houses  and  yards  contained  87  barrels,  144  buckets, 
50  earthenware  pots,  66  tin  cans,  17  stone  jars,  121  odd 
receptacles,  and  27  wells. 

Therefore,  distributed  amongst  the  200  houses  there  were 
no  less  than  500  receptacles  capable  of  holding  water,  and  in 
most  instances  water  was  present.  Larvse  were  found  in  88 
houses,  distributed  amongst  174  receptacles  out  of  the  500 
potential  water-containers ;  reckoning,  however,  that  88  houses 
out  of  200  were  found  harbouring  larvae,  the  percentage  works 
out  as  44  per  cent.  The  streets  examined  by  me  were  Circular 
Road,  Regent  and  Goodrich  Streets,  Wilberforce  Street,  Fourah 
Bay  Road,  Howe  Street,  Charlotte  Street,  Little  East  Street, 
Charles  Street,  and  Kissy  Street. 

When  I  made  my  inspection  of  Freetown  several  previous 
cleanings  up  of  the  town  had  already  been  made,  and  innumer- 
able odds  and  ends  removed.  Moreover,  as  there  is  a  pipe- 
borne  water  supply  the  necessity  for  barrels  and  water  recep- 
tacles is  greatly  diminished.  Nevertheless,  as  the  survey  shows, 
there  were  yet  numbers  of  unnecessary  water-containers  and 
wells  which  are  worse  than  useless.  The  larvae  were  in  almost 
all  cases  those  of  the  Stegomyia ;  whenever  I  was  in  doubt,  I 
took  samples  to  my  office  to  hatch  out.  Mr  Newstead,  to  whom 
I  brought  back  the  adults  for  corroboration,  informs  me  that  the 
129  specimens  were  all  Stegomyia  fasciata,  with  the  exception 
of  2  specimens  of  Culex  pruinosus.  After  examining  another 
series  of  adult  mosquitos  bred  by  Dr  J.  G.  Wood,  of  Freetown, 
from  larvae  collected  in  odd  receptacles,  Mr  Newstead  reports  as 
follows : — 

Kroobay,  Freetown,  in  rock  pool,  31.  viii.  10 : — 

3  specimens  of  Scutomyia  sugens,  Wied. 
Pulteney  Street,  Freetown,  in  cask,  25.  viii.  10 : — 

2  specimens  of  Stegomyia  fasciata,  Fab. 


290     DISTRIBUTION  OF  THE  STEGOMYIA  IN  AFRICA 

Vals  Showrooms,  Water  Street,  Freetown,  27.  viii.  10,  in  old 
tank  : — 

3  Stegomyia  fasciata,  Fab. 
Dandas  Street,  Freetown,  in  tin  and  rock  pool,  24.  viii.  10  : — 

3  Stegomyia  fasciata,  Fab. 
George  Street,  off  Upper  Brook  Street,  14.  viii.  10 : — 

1  specimen  destroyed,  1  Stegomyia  fasciata. 
Percival  Street,  in  tin,  25.  viii.  10 : — 

2  Stegomyia  fasciata,  Fab.,  2  specimens  destroyed. 
Waterloo  Street,  in  foul  tin,  26.  viii.  10: — 

3  Stegomyia  fasciata,  Fab. 

Note. — Scutomyia  sugens  is  very  nearly  related  to  Stegomyia  ; 
for  the  distinctions,  see  p.  277. 

As  the  result  of  the  examination  of  a  third  series  sent  by  Dr 
J.  G.  Wood,  Mr  Newstead  reports  : — 

John  Lane,  Freetown,  outskirts,  in  pool,  9.  ix.  10 : — 

3  Culex  invenustus,  Theo. 
Fergusson  Street,  Freetown,  in  rock  pool,  7.  ix.  10  : — 

1  Pyretophorus  costalis,  Loew, 
Ascension  Town,  Freetown,  in  pot,  10.  ix.  10 : — 

1  Stegomyia  africana,  Theo. 
Kroobay,  Freetown,  in  canoe,  31.  viii.  10 : — 

1  Culex  sp.  (?),  badly  damaged. 
Deborah  Street,  Freetown,  in  cask,  6.  ix.  10 : — 

1  Stegomyia  fasciata,  Fab. 
Soldier  Street,  Freetown,  in  old  pot,  15.  ix.  10: — 

1  Stegomyia  fasciata. 
Adelaide  Street,  Freetown,  in  lily  pot,  3.  ix.  10: — 

1  $  Stegomyia  sugens,  1  badly  damaged  Culex  sp.  (?) 
Vals  Showrooms,  Water  Street,  Freetown,  in  old  tank,  29. 

viii.  10 : — 

2  Stegomyia  fasciata,  2  Stegomyia  sugens. 
Benjamin  Lane,  Freetown,  in  cask,  9.  ix.  10 : — 

3  Stegomyia  fasciata. 


GOLD  COAST  TOWNS  291 

The  above  data  sufficiently  indicate  that  Stegomyia  fasciata 
is  by  far  the  most  prevalent  mosquito  found  in  artificial  collec- 
tions of  stagnant  water.  The  reports  show  that  in  the  course  of 
a  few  weeks  the  percentage  of  houses  infested  has  been  reduced 
from  44  per  cent,  to  J  per  cent,  and  that  it  is  possible  without 
any  large  expenditure  of  money  to  reduce  it  still  further. 

Sierra  Leone  Protectorate. — I  was  enabled  to  examine  both 
Bo  and  Kenema,  which  are  towns  in  the  interior  on  the  railroad. 
At  Bo,  in  the  native  town,  I  found  the  common  mosquito  to  be 
Stegomyia  fasciata  ;  it  was  breeding  in  barrels  and  in  all  collec- 
tions of  stagnant  water  retained  in  cans,  bottles,  or  odds  and 
ends. 

In  Kenema,  which  is  a  wonderfully  clean  native  town,  there 
is  a  pipe  supply  of  water,  and  there  are  few  barrels  or  odds  and 
ends.  I  found  Stegomyia,  however,  in  a  large  rot-hole  in  a  tree 
and  in  a  barrel  used  by  builders. 

Bullom  country. — After  making  a  sanitary  tour  of  inspection 
of  this  part  of  Sierra  Leone  in  February  1909,  the  medical 
officer  in  charge  reported  : — 

"  Stegomyia  fasciata  swarms  in  the  grass  fields  and  is  also 
common  in  the  coast  towns ;  this  being  so,  if  yellow  fever  once 
got  a  hold  of  the  country,  it  would  spread  rapidly  right  up  to 
Port  Lokko,  if  not  further." 

There  can  be  no  doubt  that  the  common  mosquito  breeding 
in  artificial  water-containers  in  Freetown  is  Stegomyia  fasciata. 
This  finding  is  in  conformity  with  what  we  know  of  yellow  fever 
in  the  Colony,  and  supports  the  view  that  the  disease  is 
endemic. 

2.   The  "  Stegomyia  "  in  the  Gold  Coast  Colony 

On  my  arrival  in  June  1910  in  the  Gold  Coast  Colony,  I 
immediately  set  to  work  to  obtain  an  estimate  of  the  prevalence 
and  numbers  of  Stegomyia  in  Secondee,  and  at  the  same  time  I 


292    DISTRIBUTION  OF  THE  STEGOMYIA  IN  AFRICA 

addressed  a  circular  letter  to  medical   officers   throughout  the 
Colony,  asking  for  information  under  the  following  heads  : — 
i.  A  return  showing  the   number  of  houses  and  yards  in 
which  Stegomyia  have  been  found. 

2.  The  nature  and  approximate   number   of  water-holding 

receptacles  in  each  house. 

3.  Any  reports  or  traditions  of  cases  of  yellow  fever  in  the 

port. 

4.  The  nature  and  extent  of  any  anti-larval  measures  which 

may  have  been  carried  out,  such  as  removal  of  odd 
receptacles,  screening  water-containers,  oiling,  bush- 
clearing,  draining  or  fish-stocking. 

Previous  to  my  arrival,  the  senior  sanitary  officer  had 
instituted  a  vigorous  removal  of  all  larva-breeding  receptacles 
from  the  yards,  and  the  screening  of  all  large  water-containers. 
He  estimated  that,  at  the  commencement  of  operations,  in  all 
probability  every  house  was  breeding  larvae ;  that  in  other 
words,  the  Stegomyia  index  was  100  per  cent. 

On  my  arrival  I  went  through  the  town  with  the  senior 
sanitary  officer,  and  the  assistant  medical  officers,  and  a  house 
to  house  inspection  yielded  the  following  results  : — 

Eight  hundred  and  forty-two  houses  were  examined,  and  in 
162,  larvae  were  met  with;  yielding  therefore  an  index  corre- 
sponding to  23  per  cent. 

The  following  are  the  figures  : — 


House  to  House  Inspection  of  the  town  of  Secondee,  from  the 
i^th  of  June  to  the  /^th  July  19 10. 


Houses  visited. 

Larvse  found. 

Percentage. 

Accra  Town        .... 

267 

29 

19 

(Dr  Muggliston) 

135 

49 

37 

(Dr  Fraser) 

376 

86 

22 

(Drs  Croley  &  Goodbrand) 

Business  Area     .... 

64 

1 

i-55 

GOLD  COAST  TOWNS  293 

Stegomyia  survey  of  Accra. 

On  the  7th  July  1910,  the  principal  medical  officer 
reported : — 

Number  of  houses  inspected,  729. 

Number  of  houses  where  larvae  or  imagines  of  Stegomyia 
were  found,  477. 

In  conjunction  with  Drs  Garland,  Rice,  and  Beamish,  I 
myself  made  a  house  to  house  inspection,  and  although  the 
inspectors  had  already  been  through  the  town,  nevertheless  I 
found  a  vast  number  of  breeding-places.  I  examined  80  houses. 
In  these  I  found  404  receptacles  of  all  kinds  containing  water  ; 
earthenware  pots  were  most  abundant.  Of  the  80  houses,  larvae 
were  found  in  61,  the  number  of  infested  receptacles  being  138. 
I  hatched  out  many  of  the  larvae,  and  Dr  Graham  confirmed  my 
diagnosis  of  Stegomyia  fasciata.  In  addition  to  finding  very 
large  quantities  of  empty  tin  cans,  it  was  noted  that  there  was 
an  excess  of  bush  all  over  the  town,  which  might  effectively 
conceal  other  such  tins  and  prevent  the  water  in  them  from 
evaporating. 

Cape  Coast  Castle,  July  19 10. — The  report  of  the  medical 
officer  states  that  "out  of  15  European  bungalows  examined 
larvae  were  found  in  13.  Larvae  were  found  in  all  native  houses 
without  exception." 

In  a  hurried  examination  which  I  made  with  the  medical 
officer  on  the  6th  July,  I  found  a  very  bad  state  of  affairs.  In 
30  houses,  or  their  yards,  there  were  32  earthen  pots,  18  barrels, 
and  3  wells,  and  larvae  were  found  in  17  of  the  30  houses; 
index  57  per  cent.     The  Stegomyia  was  the  prevailing  species. 

Axim. — The  medical  officer  reported  that  he  had  personally 
inspected  63  houses  and  found  larvae  in  6,  in  every  instance  they 
were  those  of  the  Stegomyia ;  index  9  per  cent.  Another 
report  stated  that  11 36  houses  had  been  inspected  and  in  50 
larvae  were  found  ;  index  4  per  cent. 

Elmina. — The  report  of  the  medical  officer  gave  the 
Stegomyia  index  as  33  per  cent. 


294    DISTRIBUTION  OF  THE  STEGOMYIA  IN  AFRICA 

Saltpond. — The  report  of  the  medical  officer  stated  that  275 
houses  had  been  examined  and  larvae  found  in  78  ;  index  28 
per  cent. 

Kita. — The  medical  officer  reported  the  Stegomyia  present  in 
all  houses ;  index  100  per  cent. 

Ada. — The  medical  officer  estimated  the  percentage  of 
Stegomyia  as  6  per  cent.  In  an  examination  of  houses  which 
he  made  he  was  unable  to  detect  the  Stegomyia  amongst  the 
larvae. 

Tarquah. — The  medical  officer  reported  the  index  as  10  per 
cent.  He  also  stated  that  of  136  rooms  inspected,  in  14  the 
larvae  or  the  imagines  of  the  Stegomyia  were  found.  On  the 
24th  June  I  visited  the  town,  and  in  an  examination  of  40 
houses  in  the  miners'  village  I  found  Stegomyia  larvae  in  23.  In 
my  opinion  the  prevailing  mosquito  in  Tarquah  is  Stegomyia 
fasciata. 

Obuassi. — I  inspected  100  houses  in  this  district  and  found 
191  receptacles.  Larvae  of  the  Stegomyia  were  found  in  55  of 
the  houses;  index  55  per  cent. 

Kumasi. — The  medical  officer  reported  that  in  an  examina- 
tion of  520  houses  larvae  were  found  in  48 ;  index  9  per  cent. 
On  the  2nd  July  I  myself  made  an  examination  of  the  48 
houses  and  found  the  larvae  of  the  Stegomyia  breeding  in  8. 

3.   The  "  Stegomyia  "  in  Senegal,  Ivory  Coast,  and  Dahomey 

Bouffard  pointed  out  the  prevalence  of  the  Stegomyia  in  the 
Upper  Senegal  and  French  Niger  territory  in  1906.  Ribot  and 
Le  Moal  also  drew  attention  to  the  widespread  distribution  of 
this  species  in  Senegal,  and  describe  the  various  anti-Stegomyia 
measures.  From  the  history  of  yellow  fever  in  that  country,  it  is 
evident  that  this  must  be  the  prevailing  mosquito  of  the  towns, 
and  that  it  is  widely  distributed,  reaching  as  far  as  Dioubeba  in 
the  Sudan.  In  a  more  recent  paper  Bouffard  draws  attention 
to  the  essentially  endemic  character  of  yellow  fever  throughout 
Senegal.     He  has  investigated  the  trade  routes,  both  by  road, 


—  03 


-o    o 

So 


1 
] 


DAHOMEY,  TOGO,  AND  NIGERIA  295 

rail,  and  water,  between  Koulikaro  and  Timbuktu,  Bamako  and 
Sikasso,  Segu  and  San,  and  between  Segu  and  Kutiala,  and 
finds  the  Stegomyia  in  all  centres  of  population.  This  observer 
insists  on  the  essentially  domestic  character  or  the  mosquito, 
and  that  it  is  not  as  a  rule  found  beyond  a  radius  of  ioo  metres 
from  the  dwelling  houses.  Le  Moal  gives  the  distance  as  250 
metres.  He  concludes  that  the  mosquito  is  abundantly  distri- 
buted throughout  all  the  towns  and  villages,  and  that  it  breeds 
in  the  various  receptacles  which  I  have  already  described,  and 
also  in  all  puddles  near  houses  after  rain.  For  the  safety  of 
the  white  man,  he  insists  upon  segregation  and  anti-larval 
measures.  Le  Moal  describes  the  Stegomyia  as  abundant 
throughout  Senegal,  especially  at  St  Louis  and  Goree  Islands, 
also  in  Konakry  and  at  Grand  Bassam  on  the  Ivory  Coast. 

4.   The  "  Stegomyia  "  in  German  African  Colonies 

According  to  Otto  and  Neumann,  the  mosquito  is  present 
in  Togoland,  Cameroons,  and  in  German  and  British  East 
Africa  (Ollwig).  It  is  still  doubtful  whether  it  is  present  in 
German  South- West  Africa. 

The  German  authorities  are  fully  alive  to  its  significance, 
and  have  introduced  strict  anti-stagnant  water  ordinances  for 
Togo,  in  1 9 10.  Much  more  accurate  information  is  still  wanted 
as  regards  its  distribution  and  prevalence  in  the  West  and  East 
African  colonies,  and  it  is  to  be  hoped  that  definite  information 
will  soon  be  forthcoming. 

5.   The  "  Stegomyia  "  in  Southern  Nigeria 

In  company  with  Drs  Pickels,  Laurie,  and  Tynan,  of  Lagos, 
I  made  a  thorough  house  to  house  inspection  of  100  houses, 
selected  in  representative  parts  of  Lagos,  including  the  poorest, 
lower  middle  class  and  white  trading  classes.  The  houses  in 
the  poorest  part  of  the  town  are  veritable  rat-traps,  dovetailed 
into  one  another,  and  abominably  overcrowded  for  the  amount 
of  ground  space  ;  they  are  in  consequence  very  dark,  and  in  the 


296     DISTRIBUTION  OF  THE  STEGOMYIA  IN  AFRICA 

course  of  all  my  experiences  I  have  never  yet  found  so  many 
receptacles  of  all  kinds  containing  stagnant  water,  or  containing 
such  an  immense  number  of  Stegomyia  larvae.  Altogether  in 
the  ioo  houses  and  yards  there  were  489  collections  of  stagnant 
water;  these  consisted  of  339  earthen  pots,  32  wells,  and  the 
remainder  of  buckets,  barrels,  and  odds  and  ends.  Earthenware 
pots,  therefore,  vastly  predominated  over  all  .other  water 
receptacles.  I  found  larvae  in  252  receptacles;  and  as  the 
houses  are  packed  closely  together,  I  am  of  opinion  that  it  is 
understating  the  percentage  if  it  is  placed  at  100  per  cent,  for 
unquestionably  each  house  was  infected  with  Stegomyia,  breeding 
in  its  own  yard  or  room,  or  in  the  adjacent  yard  or  hut 
Specimens  of  adult  Stegomyia  were  present  in  the  houses  in 
far  greater  numbers  than  I  have  seen  them  in  any  other  part 
of  the  Tropical  World.  The  larvae  were  in  the  vast  majority  of 
cases  those  of  Stegomyia  fasciata.  To  make  sure,  however,  I 
bred  out  numerous  batches,  which  were  submitted  to  Dr 
Graham,  who  confirmed  my  diagnosis,  and  also  found  Culex 
tigripes,  Culex  hirsutipalpis,  and  Culex  albovirgatus ;  Graham. 
Dr  Graham  had  already  drawn  attention  to  the  prevalence  of 
the  Stegomyia,  and  its  danger  from  the  point  of  view  of  yellow 
fever.  He  regards  this  mosquito  as  the  common  species  of  the 
Coast  towns.  From  the  reports  made  by  the  sanitary 
inspectors  and  furnished  to  me  by  Dr  Tynan,  there  is  no 
doubt  that  Stegomyia  fasciata  is  the  common  mosquito  of 
Lagos,  and  is  breeding  in  immense  numbers  in  that  town.  In 
the  Central  Province  of  Southern  Nigeria,  Dr  MacDonald 
considers  it  to  be  the  commonest  mosquito  found  breeding  in 
water-containers.  From  a  report  furnished  by  the  medical 
officer  of  Sapele,  the  Stegomyia  index  in  that  locality  is  13  per 
cent.  The  medical  officer  at  Warri  reports  that  before  cleaning- 
up  operations  mosquito  larvae  were  present  in  every  compound. 
The  medical  officer  at  Forcados  reports  the  Stegomyia  index  as 
being  2  per  cent  The  senior  medical  officer  of  the  Eastern 
Province  (including  Bonny  and  Calabar)  reported  in  July  1910 


EAST  AND  SOUTH  AFRICA  297 

that  every  native  house  and  compound  contained  water 
receptacles,  and  the  larvae  usually  present  were  those  of 
Stegomyia  fasciata.  The  medical  officer  at  Opobo  also  draws 
attention  in  a  report  to  the  universal  distribution  of  the 
Stegomyia  in  Southern  Nigeria,  and  the  danger  arising  from 
this  fact  were  yellow  fever  introduced. 

In  conclusion,  we  may  reasonably  assume  that,  like  Lagos, 
the  prevailing  house  mosquito  of  the  towns  in  Southern  Nigeria 
is  Stegomyia  fasciata.  This  species  has  also  been  found  at 
Brass,  Akassa,  and  Bonny,  by  Mr  J.  J.  Simpson,  and  at 
Degema,  by  Mr  A.  H.  Hamley. 

Antilarval  measures. — During  this  year,  1910,  increased 
energy  has  been  shown  in  cleaning  up  the  compounds, 
removing  odd  receptacles,  and  in  screening  tanks  and  vats ; 
fines  have  also  been  inflicted  for  neglect  of  these  precautions. 

Far  more  systematic  anti-mosquito  work  must  be  under- 
taken before  it  can  be  said  that  yellow  fever  is  not  endemic,  or 
that  there  is  no  danger  from  importation. 

6.   The  "  Stegomyia  "  in  other  Parts  of  West,  East,  and 
South  Africa 

Mr  Guy  Marshall  has  furnished  me  with  the  following  list 
of  additional  places  where  the  Stegomyia  calopus  has  been 
reported  x : — 

NORTHERN  ANGOLA  :  San  Salvador  (Br  Mercier  Gamble). 

The  Island  of  Principe  (Dr  Ansorge). 

British  Somaliland  :  Zeila  (Dr  A.f.M.  Paget). 

British  East  Africa  :  Mombasa  (/.  D.  M'Kay). 

NYAS ALAND  :  Somba  (Br  H.  S.  Stannus)  and  Blantyre  (Dr 
J.  E.  S.  Old). 

NATAL  :  Durban  (Dr  Christophers). 

1  [These  records  are  based  on  specimens  contained  in  the  British 
Museum  collection  or  received  by  the  Entomological  Research  Committee. 
Mr  M'Kay  notes  that  at  Mombasa  this  mosquito  is  common  and  trouble- 
some.— Guy  Marshall.] 


298     DISTRIBUTION  OF  THE  STEGOMYIA  IN  AFRICA 

No  information,  however,  is  forthcoming  as  regards  the 
distribution  and  abundance  of  the  insect.  It  is  to  be  hoped 
that  careful  reports  will  be  drawn  up  upon  these  important 
points. 

Destruction  of  Stegomyia  fasciata 

In  the  preceding  pages  I  have  sketched  the  wide  distribution 
of  the  Stegomyia  in  West  Africa,  and  its  significance  is  obvious, 
for  it  explains  why,  for  the  last  hundred  years  at  least,  yellow 
fever  has  been  common  on  the  coast.  It  explains  the  outbreaks 
of  yellow  fever  for  this  year  (1910),  and  it  warns  us  that  if  West 
Africa  is  to  be  still  further  developed  in  connection  with  its 
great  potential  mining,  oil,  and  other  industries,  it  will  be 
necessary  to  eradicate  the  Stegomyia  or  face  the  certainty  of 
the  disaster  and  panic  which  will  ensue  from  outbreaks  of 
yellow  fever. 

The  existence  which  I  have  endeavoured  to  show  of  the 
Stegomyia  in  overwhelming  preponderance  in  the  Coast  towns 
and  in  many  of  the  interior  towns  of  West  Africa,  also  goes  far, 
in  my  opinion,  to  explain  the  very  high  mortality  rate  amongst 
Europeans  in  the  past.  This  high  death-rate  has  as  a  rule  been 
attributed  to  malaria,  in  one  or  other  of  its  many  forms.  But  I 
think,  not  only  from  the  evidence  of  the  wide  distribution  of  the 
Stegomyia,  but  also  from  the  evidence  of  hospital  case-books 
and  the  experience  of  both  English,  French,  and  German 
medical  authorities,  that  a  very  considerable  proportion  of  the 
death-rate  may,  with  a  high  degree  of  probability,  be  ascribed 
to  yellow  fever ;  that,  in  fact,  the  disease  has  been  often  over- 
looked. In  other  words,  when  the  yellow  fever  cases  are  taken 
out,  the  malaria  death-rate  on  the  coast  is  not  unlike  the 
malaria  death-rate  of  all  other  malarial  countries ;  and  it  seems 
probable  that  the  deadly  reputation  of  West  x\frica  has  to  a 
large  extent  been  due  to  mistaken  diagnosis,  to  neglect  of 
fumigation  after  cases  of  yellow  fever,  and  above  all,  to  the 
absence  of  any  attempt  to  reduce   the   vast    numbers   of  the 


REFERENCES  299 

Stegomyia.  Therefore,  if  West  /African  development  is  to 
proceed  in  security,  it  is  necessary  to  lose  no  time  in  organising 
methods  to  combat  this  mosquito. 

References 

Le   Moal — Etudes  sur  les  moustiques  en  FAfrique  occidentale  francaise, 

Paris,  1906. 
OTTO   (L.) — "Ueber   gelbfieber   in   Afrika,"    Archiv  f    schiffs    u.    tropen 

hygiene,  Bd.  xi.,  p.  147. 
ROSS,    (RONALD) — First  Progress  Report  of  the   Mosquito   Ca?npaign   in 

Sierra  Leone,  Liverpool   School  of  Tropical  Medicine,  Memoir  V., 

part  1,  1901. 
Dutton  (J.  E.) — Report  of  the  Malaria  Expedition  to  the  Gambia,  Liverpool 

School  of  Tropical  Medicine,  Memoir  X.,  1902. 
PROUT   (W.   T.) — Lectures  on  Elementary  Hygiene  and  Sanitation,  with 

Special  Reference  to  the  Tropics,  London,  1905. 
BOUFFARD  (G.) — "  La  defense  de  Bamako  (haut  Senegal)  contre  la  fievre 

jaune,  1906,"  Bulletin  de  la  Societe  de  Pathologie  Exotique,  i.,  p.  412, 

July  1908. 
"Le  Stegomyia  fasciala  au  Soudan  Francais,"  Bulletin  de  la  Societe'  de 

Pathologie  Exotique,  October  1908. 
OTTO  und  Neumann — "  Studien  iiber  gelbfiebre  in  Brazilien,"  Zeitschrift 

f.  Hygiene,  1905. 
RlBOT — Rapport  annuel  sur  les  services  d' hygiene  du  Senegal  en  1905. 
WESCHE  (W.)— "On  the  Larval  and  Pupal  Stages  of  West  African  Culicidse," 

Bulletin  of  Entomological  Research,  vol.  i.,  part  1,  p.  7,  April  1910. 
Graham  (W.  M.)— "The  Study  of  Mosquito  Larvse,"  Bulletin  of  Entomo- 
logical Research,  vol.  i.,  part  1,  p.  51,  April  1910. 
BLANCHARD     (R.)    and    Dye    (L.)— "Sur    les    moustiques    de    TAfrique 

occidentale  francaise,"  Revue  de  med.  et  d 'hygiene  trop.,  1904,  tome 

li.,  12. 
BLANCHARD  (R.) — "  Sur  les  moustiques  de  la  cote  d'lvoire,"  C.  R.  de  la  Soc. 

de  Biologie,  1903,  p.  570. 


PART    VI 

PBOPHYLAXIS 


30J 


FlG.  45. — Using  Steam  from  the  Fire  Engine  to  destroy  Mosquitos 
in  Sheds,  Outhouses,  and  Railway  Carriages. 
New  Orleans,  1905. 


{To  face  p.  302. 


CHAPTER  XIX 

PLAN    OF   CAMPAIGN 

THIS  subject   can  best   be  studied  from    the  two   standpoints 
as  follows : — 

(A )  Where  there  is  reason  to  believe  that  yellow  fever  is  endemic. 

i.  Segregation  of  non-immunes,  partial  or  complete,  town 
planning. 

2.  Screening  : — 

The  bed. 
The  verandah. 
The  house. 

3.  Systematic  mosquito  destruction. 

Removal  of  breeding-places. 
Screening  of  water  cisterns. 
Oiling,  infliction  of  fines. 
Drainage. 
Bush  clearing. 

4.  Education. 

5.  Quarantine  administration. 

(B)  Where  yellow  fever  has  broken  out. 

1.  Removal  of  all  non-immunes  outside  the  infected  area. 
Deflection  of  the  traffic  outside  the  infected  areas. 

2.  Provision  for  the  isolation  of  all  cases,  or  suspected  cases. 

3.  Provision  for  contacts. 

4.  Early  notification. 

5.  Fumigation. 

303 


304  PROPHYLAXIS 

6.  Emergency  mosquito  measures. 

Removal  of  receptacles. 

Oiling. 

Screening. 

Drainage. 

7.  Education. 

Lectures. 

Meetings. 

Drainage. 

8.  General  organisation  of  the  medical  forces. 

A 

1.  Segregation  of  Non-immunes 

Segregation  or  protection  of  those  who  arrive  for  the  first 
time  in  any  country  where  yellow  fever  is  endemic,  is  a  self- 
evident  method  of  protection.  It  would  be  barbaric  or  uncivilised 
not  to  adopt  this  fundamental  method  of  self-protection. 

If  yellow  fever  is  endemic,  the  virus  must  be  kept  up  by  the 
inhabitants  whoever  they  may  be — blacks,  Indian-Spanish,  or 
Creoles.  Therefore  the  first  measure  of  safety  is  to  live  in. some 
quarter  away  from  the  inhabitants. 

The  nature  of  the  new  arrival's  business  may  be  such  as  to 
make  it  necessary  for  him  to  transact  it  during  the  day  in  the 
midst  of  the  houses  of  the  inhabitants.  During  the  night,  how- 
ever, he  can  usually  find  sleeping  quarters  at  a  little  distance 
away.  It  is  a  well-known  fact  that  sleeping  outside  the  native 
town  does  confer  a  very  great  measure  of  safety. 

Therefore  the  rule  should  be  wherever  possible,  to  reserve 
one  portion  of  the  town  for  special  quarters  for  the  white 
traders,  in  which  reservation  no  natives  should  be  allowed 
to  dwell. 

In  the  future  all  West  African  Coast  towns  should  be  planned 
out  with  this  segregation  in  view. 

Failing  complete  segregation,  the  next  thing  to  do  is  to 
provide  sleeping  accommodation  outside  the  native  town.    This 


Fig.  46. — A  very  carefully  screened  House  Water  Cistern. 
New  Orleans,  1905. 


{To  face  p.  £04. 


SEGREGATION  AND  SCREENING  305 

can  in  a  very  large  number  of  instances  be  readily  arranged. 
Officials  and  merchants  must  keep  in  far  better  health  if  they 
can  sleep  away  from  their  business  premises  in  a  place  secure 
from  infection  and  exposed  to  healthy  breezes.  The  small 
amount  of  time  occupied  in  going  to  and  fro  to  their  sleeping 
quarters,  is  more  than  counterbalanced  by  increased  vigour 
and  aptitude  for  work.1 

2.  At  the  present  day  it  is  hardly  necessary  to  insist  upon 
the  mosquito  net ;  it  is  now  universally  adopted,  and  the  man 
who  does  not  do  so  is  regarded  rightly  as  a  crank. 

Every  bedstead  in  the  tropics  should  be  provided  with  a 
properly  made  net,  one  that  is  an  absolute  protection  against 
the  mosquito.  Personally,  I  prefer  the  form  erected  over  a 
square  frame  under  which  a  bedstead  and  a  small  table  can 
readily  fit.  Very  excellent,  however,  are  the  small  mosquito 
nets  fitted  to  camp  beds.  They  are  exceedingly  comfortable,  and 
with  one,  one  can  travel  anywhere  and  sleep  with  the  assurance 
of  absolute  safety  from  infection.  There  is  no  doubt  that 
during  the  last  ten  years  the  use  of  the  mosquito  net  has 
become  universal,  and  it  is  to  this  reason  that  we  must  ascribe 
in  very  large  measure  the  decrease  of  both  malaria  and 
yellow  fever. 

Sometimes  it  is  possible  to  screen  the  whole  of  a  house,  or 
portion  of  the  verandah.  If  house  screening  is  resorted  to, 
it  must  be  very  carefully  looked  after  to  see  that  no  holes  are 
formed,  and  that  mosquitos  cannot  possibly  gain  access  inside. 
If  this  is  not  done  the  screening  may  turn  out  worse  than  useless. 
The  same  measure  of  security  can  be  obtained  by  the  use  of 
a  simple  portable  screened  chamber,  which  one  can  erect  in  a 
few  minutes  over  a  sofa  or  couple  of  chairs  and  a  table.  It  is  a 
great  comfort  to  be  able  to  rest  in  the  afternoon  free  from  the 
risk  of  infection,  that  is,  if  one's  house  is  near  native  houses. 

I  wish,  however,  to  emphasise,  that  the  greatest  security  will 

1   For  many  years  sleeping  out  of  town  was  the  rule  in  Rio  and  Santos 
during  the  yellow  fever  period  of  a  few  years  ago. 

U 


306  PROPHYLAXIS 

be  attained  by  placing  the  house  at  a  safe  distance  from  the 
native  town,  on  some  advantageous  site,  free  from  bush  and 
freely  exposed  to  every  breeze. 

3.  Mosquito  Destruction 

This  is  a  measure  which  strikes  at  the  root  of  all  the  evil, 
and  affords  security  to  all  alike,  be  they  white,  black,  or  yellow- 
skins.  Fortunately,  public  opinion  has  begun  to  recognise  that 
this  is  a  comparatively  inexpensive  and  practical  measure,  and 
shows  a  return  almost  immediately  in  increased  comfort  and 
health.  It  is,  moreover,  a  measure  in  which  everyone,  man, 
woman,  and  child  can  co-operate.  The  work  divides  itself  into 
the  following  divisions. 

(1)  Removal  of  odd  breeding-places,  such  as  tins  of  all 
kinds,  bottles,  calabashes,  broken  and  disused  crockery,  etc.,  etc. 
This  is  work  which  everyone  can  help  to  do.  To  help  it 
effectually  the  Health  Authority  must  employ  more  sanitary 
inspectors  and  more  dust  carts.  But  it  is  for  each  householder 
to  see  that  the  rubbish  is  removed  to  a  place  where  it  cannot 
do  any  harm. 

(2)  Screening. — If  the  town  is  not  fortunate  to  possess  stand 
pipes,  then  it  is  very  essential  to  see  that  all  proper  water 
receptacles,  such  as  barrels  and  cisterns,  are  suitably  protected 
with  wire  gauze,  or  otherwise  made  mosquito  proof.  This  is 
absolutely  essential,  and  if  not  seen  to,  the  traders'  houses  often 
become  the  worst  offenders. 

(3)  Oiling. — Of  course  the  better  plan  to  deal  with  pools  and 
defective  storm  water  drains  is  to  fill  them  in  and  do  away 
with  them  ;  but  to  quickly  deal  with  them,  the  simplest  plan  is 
to  sprinkle  every  week  a  little  kerosene  oil  over  them.  The 
householder  should  do  this  ;  it  is  most  effective  and  cheap. 

4.  Experiments  upon  the  Culicidal  Action  of  Kerosene  Oil 
The   most  economical,  least  dangerous,  and   most   readily 
procured     of  all    culicides,    are    the   various    preparations    of 


FlG.  47. — The  Oiling  and  Screening    Gang,  ready  to  start 
for  the  day's  work.      New  Orleans,   1905. 


FlG.  48. — The  Screening  Gang  at  work  securing  the  Cisterns. 
New  Orleans,  1905. 


[To  /ace  p.  306. 


CULICIDES  307 

petroleum.  This  oil  can  be  used  on  a  large  or  small  scale,  and 
it  can  be  either  sprayed  or  poured  on  the  water.  For  all 
stagnant  collections  of  water  in  pools  or  lagoons  it  is  excellent, 
and  its  culicide  action  remains  long  after  such  collections  of 
water  have  been  treated.  It  must  be  recollected  that  under  a 
powerful  tropical  sun,  the  oil  evaporates  in  a  comparatively  short 
period,  and  that  therefore  the  treatment  must  be  renewed  every 
few  days.  I  made  some  experiments  this  year  in  order  to 
determine  how  soon  the  effect  of  the  oil  passed  off  My  experi- 
ments consisted  in  placing  in  a  large  tub  of  water,  of  one  square 
yard  superficial  measurement,  a  number  of  the  larvae  of  the 
Stegomyia.  Then  I  poured  on  to  the  surface  I  oz.  of 
kerosene  oil,  and  exposed  the  tub  either  in  the  bright  sunshine, 
or  kept  it  under  shade.  I  timed  the  starting  of  the  experiment, 
and  the  time  when  the  larvae  ceased  to  move. 

Experiment  I.  —  Surface  covered  with  i  oz.  of  oil  and 
exposed  to  powerful  sun. 

Stegomyia  larvae  placed  in  water  at  12  noon;  at  3  P.M.  all 
larvae  dead,  and  most  of  the  oil  evaporated. 

Experiment  II. — To  determine  rate  of  evaporation.  At  the 
end  of  three  hours  the  oil  had  evaporated,  leaving  but  a  faint 
smell  and  producing  only  a  slight  oil  stain  on  blotting-paper. 

Experiment  III. — Half  an  ounce  of  oil  poured  on  the  water. 
Larvae  placed  in  the  water  at  12.30  P.M.;  and  all  dead  at 
1.30  P.M. ;  at  5.25  p.m.  the  oil  had  evaporated,  with  the  exception 
of  a  faint  odour  and  very  slight  iridescence.  I  then  placed  fresh 
Stegomyia  larvae  in  the  tub  without  adding  any  additional  oil, 
and  at  6.30  the  larvae  were  dead.  It  appears  that  the  small 
quantity  of  dissolved  oil  has  a  culicide  action. 

Experiment  IV. — Half  an  ounce  of  oil  poured  on  to  the 
surface  of  water  in  the  tub,  and  larvae  placed  in  the  water  at 
1.40  P.M.  in  bright  sunshine;  at  3.15  P.M.  the  larvae  were  very 
sluggish  but  still  alive  ;  the  petroleum  had  evaporated  from  the 
surface.  These  few  experiments  show  that  in  bright  sunshine 
the  oil  film  rapidly  evaporates,  but  that  the  oil  which  remains 


308  PROPHYLAXIS 

in  solution  still  continues  to  exert  a  culicide  action.  Therefore 
it  may  be  concluded  that  I  oz.  of  oil  to  the  square 
superficial  yard  is  sufficient  to  kill  mosquito  larvae,  but  that  the 
water  should  be  treated  once  a  week  in  order  to  avoid  all  risk 
of  the  survival  of  larvae. 

(4)  Drainage  and  filling  in. — Every  householder  could  assist 
the  local  authority  in  this  respect.  He  could  look  after  the 
proper  grading  of  his  own  garden  or  yard,  and  see  that  all 
depressions  are  filled  in.  That  his  roof  gutters  do  not  sagg  and 
that  if  they  do,  that  holes  are  drilled  in  them  at  intervals  of 
about  3  feet.  It  is  the  duty  of  the  local  authority  to  look 
after  the  roads  and  the  side  drains.  The  proper  grading  of 
road  levels  and  curves,  and  the  best  forms  of  storm  water  drains 
to  employ  in  the  tropics  are  matters  now  well  understood  (see 
Health  Progress  in  the  West  Indies'). 

I  would  advise  in  those  cases  where  towns  are  about  to 
embark  upon  drainage  schemes,  to  first  ascertain  what  can  be 
done  at  once,  for  a  very  little  outlay,  in  the  way  of  getting  rid  of 
all  water-holding  rubbish  and  redundant  water  storage  vessels 
and  bush.  In  other  words,  not  to  embark  upon  elaborate 
schemes  until  it  is  seen  what  can  be  done  by  a  little  individual 
enterprise  upon  the  part  of  each  inhabitant. 

If  finally  a  scheme  is  decided  upon  let  it  be  comprehensive 
for  both  the  present  and  future  requirements  of  the  locality,  and 
so  planned  that  it  can  be  undertaken  in  parts  as  occasion  arises. 

The  costly  mistake  is  too  often  made  of  putting  in  drains 
which  in  a  few  years  not  only  do  not  drain,  but  actually  form 
miniature  lakes.  It  must  also  be  remembered  that  if  drains  are 
constructed  they  must  be  kept  in  proper  repair,  and  due  allow- 
ance must  be  made  for  that  purpose  in  the  estimates. 

Canalisation. — In  the  case  of  mangrove  swamps,  very  often 
the  most  efficient  and  economical  treatment  is  to  canalise  them 
(see  my  Honduranian  Report).  By  this  means  the  water  is 
deepened  and  the  breeding  of  fish  is  favoured.  Sometimes  also 
by  these  means  it  is  possible  to  get  the  sea-water  to  enter ;  in 


FlG.  49. — Old  Style  of  filling  in   a  Swamp  by  means  of  Hand  Labour. 
Gold   Coast,   1910.     (From  Mosquito  or  Man  ?~) 


Fl<;.    50. — -Modern  Method  of  filling  in  a  Swamp  by  means  of  a  powerful  Sand  Pump. 

Lagos,   1 910. 


[  To  face  p.  308. 


DRAINAGE  AND  FISH  STOCKING  309 

this  case  a  daily  tidal  rise  and  fall  is  maintained,  which  acts  as 
an  excellent  drainage  system  (see  British  Guiana  in  Health 
Progress).  By  canalisation  it  is  also  possible  to  make  the 
margin  of  the  swamp  sharp  and  free  from  weeds.  It  will  be 
remembered  that  it  is  at  the  margins  of  swamps  where 
mosquitos  breed. 

Filling  in. — By  this  method  the  nuisance  is  altogether 
abolished.  In  my  Honduranian  Report  in  1905,  I  advocated  the 
use  of  sand  pumps  for  this  purpose.  I  have  since  seen  them  at 
work  filling  in  swamps  in  Southern  Nigeria,  and  there  is  no 
doubt  that  it  could  in  time  alter  the  health  conditions  of  many 
places  in  West  Africa  and  elsewhere.  It  is  efficient  and  cheaper 
than  hand  labour. 

It  must  not  be  forgotten,  in  filling  in  lagoons  and  swamps, 
that  as  they  are  the  natural  drainage  places  of  the  locality  and 
therefore  at  the  lowest  level  in  the  locality,  that  provision  must 
be  made  to  take  away  the  water  which  previously  drained  into 
the  lagoon.  This  can  readily  be  done  by  reserving  an  ample 
central  drain  in  the  middle,  and  into  which  by  means  of  weep 
holes  the  water  can  readily  drain  from  both  sides. 

Fish  stocking. — Following  upon  the  natural  immunity  from 
malaria  which  Barbados  has  experienced,  owing  to  the  fact  of 
the  presence  of  small  fish,  known  as  millions,  Geradinus 
pcecilloides,  fish  stocking  has  come  into  practice  and  is  a  useful 
auxiliary  method  of  defence. 

Anti-mosquito  ordinances  and  infliction  of  fines. — In  my  work 
on  Health  Progress  and  Administration  in  ihe  West  Indies,  I 
have  brought  together  the  laws  which  have  been  framed  against 
mosquitos  in  the  West  Indies.  In  the  present  volume  I  have 
summarised  some  of  those  which  are  in  use  in  West  African 
Colonies  (see  Chapter  XXL).  There  is  not  the  least  doubt  that 
these  laws,  when  enforced,  bring  about  an  immense  improvement ; 
and  it  is  further  a  fact  that  if  these  laws  are  rigorously  enforced 
without  favour  against  rich  and  poor  alike,  that  there  is  little  or 
no  opposition  from  the  public.     The  immediate  returns,  in  the 


310  PROPHYLAXIS 

form  of  greater  comfort  and  health  soon  convinces  the  public 
that  these  measures  are  wise  and  for  the  general  good  of  the 
community. 

Pipe-borne  water  supplies. — Where  a  community  can  intro- 
duce a  pure  wholesome  water  supply  laid  on  to  each  house  and 
to  stand  pipes  in  the  roads,  one  of  the  first  steps  in  the  getting 
rid  of  mosquito-carried  diseases  is  taken,  for  a  tap  water  supply 
does  away  with  the  necessity  of  storing  any  water  upon  the 
premises  ;  therefore  there  is  no  question  of  screening  cisterns 
or  barrels.  Furthermore  and  of  still  greater  importance  is  the 
getting  rid  of  the  horrible  surface  drinking  wells  which  are  found 
all  over  the  tropics,  and  which  not  only  breed  but  become  con- 
taminated with  all  kinds  of  pathogenic  bacteria  and  parasites. 

Bush  clearing. — Regular  systematic  bush  clearing  is  an 
absolute  essential  in  any  tropical  town,  overgrown  bush  causes 
as  much  harm  as  puddles  and  marshes.  It  prevents  proper 
evaporation  and  drying  of  the  ground ;  it  shuts  out  breezes ;  it 
gives  cover  to  all  kinds  of  tins  and  rubbish  which  breed 
mosquitos,  and  it  serves  as  cover  for  mosquitos.  Therefore  bush 
clearing  regulations  should  be  inserted  in  all  anti-mosquito  by- 
laws. In  getting  rid  of  bush,  each  householder  could  assist. 
At  the  present  time  all  over  the  tropics,  yards  and  gardens  are 
allowed  to  become  choked  by  useless  weeds  and  bush  of  all 
kinds.    The  Health  Authority  should  rigorously  insist  upon  bush 

clearing. 

4.  Education 

Educational  prophylaxis  is  rightly  regarded  in  all  civilised 
countries  as  a  very  great  factor  in  the  progress  of  sanitation. 
Real  progress  is  only  made  in  proportion  to  the  intelligence  and 
progress  of  the  community.  Therefore  every  endeavour  should 
be  made  to  educate  the  people  by  training  the  children  in  the 
schools,  by  teaching  the  adults  by  means  of  popular  lectures  and 
lantern  demonstrations.  The  support  of  the  clergy  of  all 
denominations  should  be  secured,  as  they  have  an  excellent 
machinery  ready  to  hand  for  teaching  the  public. 


SEGREGATION  OF  NON-IMMUNES  31 1 

5.  Quarantine  Administration 

Whether  yellow  fever  is  endemic  or  is  only  liable,  owing  to 
the  abundance  of  Stegomyia,  to  break  out  if  the  disease  were 
imported,  quarantine  regulations  have  a  very  practical  value.  A 
quarantine  station  both  for  the  isolation  of  yellow  fever  cases 
and  for  the  observation  and  detention  of  suspects  should  be 
provided.  A  ship  calling  at  a  port  where  yellow  fever  is 
endemic,  has  non-immunes  on  board,  and  these  must  be 
protected  on  the  principle  of  segregation. 

Non-immunes  must  not  be  allowed  ashore  into  the  town,  and 
the  ship  must  be  moored  at  a  safe  distance  from  shore  so  as  to 
avoid  Stegomyia  coming  on  board  and  infecting  the  non- 
immunes. Lighters  coming  alongside  must  be  previously 
treated  with  kerosene,  and  if  closed  ones,  fumigated. 

Every  passenger  coming  on  board  should  be  supplied  with  a 
health  certificate  by  the  medical  officer  on  shore. 

B. — In  those  Cases  where  Yellow  Fever  has  broken 

out 

Protection  of  the  Non-immunes 

The  first  precautionary  steps  to  take  when  yellow  fever 
breaks  out  in  a  locality,  is  to  secure  the  safety  of  the  non- 
immunes. This  is  done  by  removing  them  to  a  place  outside 
the  infected  area ;  it  is  in  fact  emergency  segregation. 

A  temporary  camp  has  to  be  erected  if  there  are  no  existing 
buildings  which  can  be  used  for  the  occasion.  If  the  epidemic 
shows  signs  of  progressing,  it  is  imperative  for  all  non-immunes 
to  live  both  night  and  day  in  the  segregation  camp.  In  less 
severe  cases  sleeping  away  from  the  infected  area  at  night-time 
affords  a  great  measure  of  security.  The  plan  of  removing  at 
once  the  non-immunes  has  been  adopted  with  signal  success 
this  year,  1910,  at  Secondee,  and  also  at  Bamako  in  1906. 


"312  PROPHYLAXIS 

Deflection  of  the  Traffic 

In  order  to  interfere  with  trade  as  little  as  possible,  it  may  be 
advisable  to  deflect  away  from  the  infected  town  or  quarter  all 
through  traffic.  A  new  temporary  port  can  be  established  for 
the  steamers,  and  a  temporary  railway  terminus  can  be  fixed 
upon,  so  as  to  avoid  running  the  trains  or  passengers  into  the 
infected  town. 

This  plan  was  adopted  with  great  advantage  at  Secondee 
(see  Chapter  XX 1 1 1.).  Goods  should  be  packed  during  the  day- 
time in  sheds  freely  exposed  to  currents  of  air.  The  greatest 
care  should  be  taken  that  the  Stegomyia  is  not  breeding  in  the 
vicinity,  and  from  time  to  time  the  sheds  should  be  steam 
fumigated.  Having  made  arrangements  for  the  safety  of  the 
non-immunes,  the  next  step  is  to  strictly  supervise  the  care  of 
the  infected,  so  that  they  cannot  become  a  source  of  infection  to 
others.  For  this  purpose  it  is  necessary  to  establish  screened 
emergency  wards,  rooms  or  an  hospital  in  a  convenient  place  to 
which  all  cases  or  suspected  cases  can  be  removed  and  carefully 
nursed  and  watched.  In  those  cases  where  it  is  inadvisable  to 
remove  the  patient,  the  room  in  which  the  patient  is  kept  must 
be  most  carefully  screened,  and  the  remainder  of  the  house 
must  be  fumigated. 

When  a  case  of  yellow  fever  is  reported,  or  where  any 
suspicious  cases  come  to  light,  the  invariable  rule  is  to  at  once 
place  the  patient  under  a  mosquito  net,  so  as  to  avoid  any 
further  chance  of  infection.  If  an  emergency  hospital  is 
established,  it  avoids  a  great  deal  of  worry  and  loss  of  time. 
The  patient  can  be  removed  at  once  under  a  mosquito  net  or  in 
a  screened  ambulance,  and  then  the  house  in  which  the  patient 
resides  can  be  thoroughly  fumigated  in  every  part ;  this  is  very 
difficult  to  accomplish  if  the  patient  remains  in  the  house. 

Upon  the  thoroughness  in  detecting  early  cases  or  suspected 
cases,  and  in  applying  fumigation,  will  depend  the  cutting  short 
of  the  epidemic. 


FlG.  52.— The  Papering  Gang  at  work,  rendering  rooms  tight 
before  Fumigation.      New  Orleans,   1905. 


Fig.   53.— A  Carefully-papered  Outhouse,   ready  for  Fumigation. 
New  Orleans,   1905. 


[To  face  p.  312. 


NOTIFICATION  AND  FUMIGATION  313 

Provision  for  Contacts 

It  is  often  a  matter  of  great  practical  difficulty  to  prevent 
relations  and  visitors  getting  access  to  a  yellow  fever  patient. 
Yellow  fever  is  constantly  spread  by  non-immunes  visiting  a 
patient,  and  then  getting  bitten  by  an  infected  Stegomyia.  For 
the  same  reason  wakes  must  be  strictly  forbidden.  When  a 
patient  is  suspected  of  having  yellow  fever,  none  but  the  nurse  and 
medical  attendants  should  enter  the  sick  room. 

When  a  person  becomes  infected  with  yellow  fever  in  a 
particular  house,  it  is  reasonable  to  suppose  that  others  also  in 
the  house  may  have  been  bitten  by  the  same  infected  Stegomyia. 
Therefore,  all  residing  in  the  house,  or  who  have  visited  at  the 
house,  should  be  kept  under  careful  observation  until  the  incuba- 
tion period  is  well  over.  Provision  should  therefore  be  made  for 
contacts  at  an  early  stage  in  the  epidemic. 

Early  Notification 
Nothing  in  yellow  fever  prophylaxis  is  so  insisted  upon  as 
this,  nevertheless,  and  in  spite  of  all  warnings,  nothing  is  so 
much  neglected.  Not  an  epidemic  passes  without  a  case  of 
yellow  fever  being  declared  in  the  third,  fourth,  or  fifth  day  of 
the  illness,  that  is  to  say  when  all  the  harm  will  have  been  done 
owing  to  failing  to  rigidly  isolate  during  the  infectious  period, 
and  failing  to  exterminate  infected  Stegomyia.  Medical  officers 
appear  always  to  be  reluctant  to  alarm  the  friends  of  the  patient 
by  declaring  yellow  fever.  It  is,  however,  in  the  very  best 
interests  of  the  patient  and  of  the  community  to  take  no  risks 
from  the  very  commencement  of  the  illness. 

Fumigation 
It  is  only  the  trained  medical  man  who  can  thoroughly 
appreciate  the  significance  of  complete  fumigation.  Laymen 
cannot  understand  the  risks  from  the  bites  of  infected  Stegomyia, 
nor  the  ease  with  which  infected  Stegomyia  hide  in  the  house  in 
which  yellow  fever  has  occurred. 


314  PROPHYLAXIS 

Therefore  fumigation  must  be  carried  out  under  the  direct 
supervision  of  a  medical  officer.  Sulphur  is  the  common 
fumigating  agent  used  all  over  the  world,  and  is  one  of  the  very 
best  materials.  The  fumes  can  be  generated  in  a  pot,  by  burn- 
ing sulphur,  or  in  a  Clayton  apparatus.  Sulphur  vapour,  however, 
tarnishes  all  brass  and  copper  work  and  all  bright  steel. 

The  following  are  the  directions  for  the  use  of  various 
fumigating  materials. 

1.  Sulphur. — Allow  2  lb.  of  sulphur  to  1000  cub.  ft.     Use  2 

pots,  place  them  in  a  pan  containing  1  in.  of  water  to 
prevent  damage,  and  set  fire  to  the  sulphur  by  means  of 
spirit.     Duration. — Three  hours. 

2.  Pyrethrum. — Allow    3    lb.    to    1000    cub.    ft.    and    divide 

amongst  2  or  3  pots,  using  the  same  precautions  as  with 
sulphur.     Duration. — Three  hours. 

3.  Camphor  and  Carbolic  Acid. — Equal  parts  camphor  and 

crystallised  carbolic  acid  are  fused  together  into  a  liquid 

by  gentle   heat.      Vapourise  4  oz.  of  mixture  to  each 

IOOO  cub.  ft. ;  this  can  be  done  by  placing  the  liquid  in 

a   wide  shallow  pan  over  a  spirit  or  petroleum  lamp ; 

white  fumes    are   given   off.      To    avoid   the    mixture 

burning,  the  fumes  should  not  come  in  close  contact  with 

the  flame  of  the  lamp.     Duration. — Two  hours. 

It  must  be  borne  in  mind  that  it  is  by  no  means  easy  to  seal 

effectively  a  bungalow  in  the  tropics,  and  much  more  difficult  to 

seal  a  thatched  hut  of  a  native.     All  that  can  be  said  is  that  it 

has  been  done  and  can  be  done  with   patience  and  plenty  of 

assistance.     Plenty  of  paste  and  all  the  paper  that  can  be  found 

in  the  town  should  be  brought  together,  and  every  chink  closed. 

Failing  paper,  recourse  may  be  had  to  cheap  cotton,  cloth,  or 

material  of  that  nature.     Sometimes  sails  or  deck  awnings  can 

be  used  to  wrap  round  and  cover  a  small  hut  or  a  verandah. 

The  details  of  sealing,  however,  must  be  left  to  the  intelligence 

and  energy  of  the  medical  officer  in  charge.    The  medical  officer 

should  have  a  free  hand,  and  the  funds  at  his  disposal  should 


FlG.  54. — Generating  the  Sulphur  in  the   Clayton   Apparatus.      Secondee,   1910. 


FlG.   55. — Photo  showing  the  Clayton  Sulphur  Apparatus  disinfecting  a  house  in  Secondee,  1910. 


[To  face  p.  314. 


EMERGENCY  MEASURES  315 

not  be  stinted.  It  is  far  more  economical  to  commence  at  once 
to  face  the  worst  and  to  prepare  accordingly.  Yellow  fever 
prophylaxis  cannot  be  scamped. 

Emergency  Mosquito  Measures 

The  outbreak  of  yellow  fever  is  always  a  good  reason  to 
redouble  the  efforts  to  get  rid  of  mosquitos.  For  this  purpose 
it  is  the  rule  to  form  clean-up  clubs,  and  to  organise  mosquito 
brigades,  and  to  set  apart  clean-up  days.  In  this  way  a  yellow 
fever  epidemic  is  a  blessing  in  disguise,  for  a  town  is  far  purer 
after  a  visitation  of  this  disease. 

For  the  same  reason  public  lectures  can  be  increased,  hand 
bills  and  pamphlets  circulated  and  affixed  in  all  public  places. 
At  this  stage  the  clergy  can  be  of  great  use,  for  as  a  rule,  they 
are  amongst  the  earliest  to  suffer  by  the  disease,  and  are  there- 
fore anxious  to  help. 

An  outbreak  of  yellow  fever  is  also  a  reason  for  organising 
the  medical  forces  of  a  district,  and  the  opportunity  should  not 
be  lost  of  bringing  all  together  to  wage  war  on  the  mosquito. 


CHAPTER   XX 

EARLY   NOTIFICATION   AND   NOTIFICATION    FEAR 

From  the  symptoms  which  I  have  described  under  "  experi- 
mental yellow  fever,"  "  inflammatory  fever,"  "  bilious  and 
remittent  fever,"  it  is  very  clear  that  yellow  fever  must  be  a 
disease  which,  in  its  milder  and  more  common  forms,  is  not 
easily  recognised.  Indeed  Carroll  states  that  "their  experi- 
ments show  that  genuine  yellow  fever  may  be  so  mild  in 
character  that  no  man,  no  matter  how  extensive  his  experience 
may  have  been,  would  dare  to  diagnose  it  as  such  unless  he 
knew  the  disease  to  be  prevailing  at  the  time." 

The  young  medical  officer  should  therefore  remember  that 
his  professional  skill  need  not  be  criticised  should  he  diagnose 
as  a  case  of  yellow  fever  one  which  subsequently  proves  to  be 
another  disease.  In  the  very  best  interests  of  the  community, 
it  is  much  safer  when  there  is  the  least  doubt  to  regard  the 
case  as  one  of  yellow  fever  and  treat  it  as  such. 

In  West  Africa  in  future  far  greater  hesitation  will  be 
necessary  before  a  case  is  assumed  not  to  be  one  of  yellow 
fever.  The  outbreak  in  the  year  1910  did  not  come  from  the 
clouds  or  have  a  spontaneous  origin,  it  must  have  been  pre- 
ceded by  other  cases  which  passed  unobserved,  and  this  is 
happening  all  the  time — it  is  universal  experience  in  endemic 
countries.  In  other  words,  the  medical  man  must  in  the  future 
ever  have  before  him  the  possibility  of  yellow  fever  as  long  as 
the   Stegomyia  is   abundant.     This  is  a  golden  rule,  and  the 

316 


EARLY  DIAGNOSIS  317 

presence  of  the  Stegomyia  should  be  made  the  test  in  all 
doubtful  cases. 

In  all  civilised  countries  liable  to  yellow  fever,  it  has  been 
held  that  it  is  the  bounden  duty  of  the  medical  officer  to  notify 
all  suspicious  cases ;  indeed  "  suspicious  of  yellow  fever "  is 
regarded  as  a  notifiable  diagnosis  in  Cuba.  It  is  the  only  way 
to  attain  security,  and  ultimately  to  get  rid  of  the  disease. 

It  is  a  melancholy  fact  to  have  to  record,  that  early  diagnosis 
in  the  case  of  yellow  fever,  and  indeed  of  other  infectious  diseases, 
is  the  exception  rather  than  the  rule.  The  young  medical  officer 
is  unquestionably  apt  to  shrink  from  making  a  diagnosis  which 
will  focus  attention  on  him,  and  perhaps  bring  him  into  ridicule 
should  his  diagnosis  not  prove  correct. 

All  young  medical  officers  should,  however,  remember  that 
they  have  the  greatest  living  authorities  on  their  side  upon  the 
question  of  having  no  trace  of  hesitation  in  diagnosing  a  case, 
when  there  are  reasonable  grounds  for  suspicion. 

I  have  repeatedly  been  told  by  medical  men,  after  the  pass- 
ing of  an  outbreak  of  yellow  fever,  that  had  they  at  the 
beginning  of  the  outbreak  the  knowledge  of  the  disease  which 
they  subsequently  possessed,  they  would  have  diagnosed  far 
more  cases  at  the  commencement  of  the  outbreak  than  they 
did ;  and  on  going  over  their  case-books  they  were  able  to 
point  out  very  numerous  instances  of  mistaken  diagnosis.  In 
discussing  the  outbreak  of  yellow  fever  in  Barbados,  1909,  which 
I  was  called  upon  to  investigate,  I  wrote  as  follows : — 

The  Diagnosis  of  the  Early  Cases 

"  The  question  naturally  arises :  Do  the  notified  cases  in 
any  epidemic  represent  the  true  total  of  all  cases?  In  my 
opinion,  the  answer  here  is  the  same  that  has  to  be  given  in 
all  these  outbreaks :  that  in  all  probability  there  were  many 
other  cases  which  were  not  correctly  diagnosed.  There  was  a 
divergence  of  opinion  amongst  the  medical  men  as  to  whether 
the  cases  were  yellow  fever  or  not,  and  the  press  was  not  slow 


318  PROPHYLAXIS 

to  make  use  of  this  want  of  unanimity  during  the  outbreak  ; 
cases  of  illness  were  diagnosed  as  gastric  influenza,  epidemic 
jaundice,  malignant  jaundice,  and  dengue.  Of  course  these 
diagnoses  were  made  in  absolute  good  faith  by  competent 
medical  men ;  but  for  all  that,  there  may  have  been  mistakes, 
and  some  of  the  cases  might  have  been  yellow  fever.  I  gathered, 
from  my  conversations  with  the  medical  men,  that  this  was 
indeed  probably  what  did  occur.  I  mention  these  difficulties 
because  they  invariably  happen  in  practice,  and  because  they 
demonstrate  the  absolute  necessity  of  a  medical  head  in  the 
Colony,  who,  by  virtue  of  his  position,  can,  when  he  deems  it 
advisable,  bring  about  the  information  of  a  friendly  consultative 
committee  of  the  medical  men  of  the  Colony  to  act  as  a  jury  in 
medical  questions  affecting  the  welfare  of  the  Colony." 

Notification  Fear 

On  looking  over  the  history  of  yellow  fever  in  any  country, 
it  becomes  clearly  obvious  that  great  confusion  has  arisen  over 
what  should  be  called  yellow  fever  or  not.  Countries  where 
yellow  fever  is  old  established  in  its  endemic  form  have  argued 
that  yellow  fever  is  only  a  disease  of  the  newcomer,  and  that 
as  far  as  the  residents  are  concerned,  they  do  not  get  it ;  at 
least  in  that  particular  severe  form. 

Some  countries  like  Cuba  would  not  diagnose  yellow  fever 
unless  black  vomit  was  present.  In  other  words,  it  became 
customary  in  some  parts  of  the  tropical  world  not  to  diagnose 
yellow  fever  unless  the  exceptional  and  severe  symptoms  were 
present.  The  mild,  commoner  form  passed  under  a  variety  of 
names  as  we  shall  see  later.  It  was  essentially  of  the  nature  of 
an  "acclimatising  fever,"  peculiar  to  the  place,  not  imported. 
Probably  it  was  in  those  days  assumed  to  be  miasmatic,  and 
produced  by  the  altered  conditions  in  which  the  new  arrival 
found  himself.  This  fever  was  looked  upon  as  the  necessary 
tax  for  coming  to  a  tropical  country.  Those  who  got  it  became 
"  salted  "  and  "  old  coasters,"  and  were  those  who  subsequently 


NOTIFICATION  FEAR  319 

openly  ridiculed  any  idea  that  yellow  fever  could  possibly  be 
present  amongst  them.  From  time  to  time,  however,  when 
large  bodies  of  newcomers  arrived,  epidemics  did  occur  which 
could  not  be  concealed,  and  the  narratives  of  the  survivors  of 
the  terrible  symptoms,  fostered  an  exaggerated  idea  of  the 
very  deadly  and  horrible  nature  of  yellow  fever.  Yellow  fever 
soon  became  to  be  regarded  as  an  awful  and  mysterious  disease, 
which  paralysed  enterprise  and  commerce.  As  a  natural  result 
of  this  there  arose  stricter  quarantine  regulations,  and  as  a 
consequence  of  this  stricter  supervision,  there  arose  a  natural 
disinclination  amongst  merchants  and  others  to  declare  yellow 
fever  if  they  possibly  could  avoid  doing  so. 

This  reluctance  has  been  universal,  and  exists  at  the  present 
day.1  There  appears,  as  it  were,  to  have  been  a  universal 
conspiracy  to  deny  the  presence  of  yellow  fever,  both  from  the 
point  of  view  that  it  was  of  no  account,  only  attacking  the  new 
arrival  ;  secondly,  from  the  fact  that  quarantine  authorities 
were  insisting  on  rigid  regulations  ;  and  thirdly,  that,  as  its  name 
caused  such  a  panic  amongst  the  public,  the  better  and  more 
business-like  policy  was  to  say  nothing  about  the  disease,  either 
deny  its  existence,  or  return  it  as  some  other  disease,  or  make 
light  of  it.  I  am  convinced  from  many  investigations  and 
from  the  careful  analysis  of  innumerable  outbreaks  of  yellow 
fever,  in  different  parts  of  the  world,  that  this  attitude  has 
prevailed. 

The  evidence  furnished  from  West  Africa  shows  that  it 
certainly  exists  there. 

Looking  at  yellow  fever  in  the  light  of  modern  discoveries, 
the  dread  of  declaring  the  existence  of  this  disease  appears 
foolish  in  the  extreme,  as  one  of  the  greatest  authorities  on 
yellow  fever  has  said  there  ought  not  to  be  any  more  hesitation 
about   its   notification    than   about   a   case   of    measles.      The 

1  Bdrenger-FeVaud  especially  blames  the  British  race  and  speaks  of  the 
invincible  reluctance  of  the  English  to  acknowledge  that  they  could  by  any 
possibility  have  yellow  fever  in  their  colonies. 


320  PROPHYLAXIS 

abnormal  fear  produced  by  its  diagnosis  is  only  the  result  of 
ignorance.  To-day  the  means  of  controlling  and  stamping  out 
this  disease  is  if  anything  more  easy  of  execution  than  in  the 
case  of  measles. 

In  addition  to  the  admittedly  great  difficulty  encountered 
in  making  a  diagnosis,  the  physician  has  often  to  put  up  with 
difficulties  of  another  sort,  namely,  these  brought  about  through 
prejudice  or  commercial  interests. 

It  seems  very  strange  that  there  should  be  obstacles  in  the 
way  of  the  diagnosis  of  yellow  fever  ;  but  such  is  the  case.  In 
all  the  outbreaks  which  I  have  had  to  investigate  I  have 
encountered  them,  and  writers  upon  yellow  fever  have,  time 
and  time  again,  drawn  attention  to  this  point. 

I  encountered  it  in  a  particularly  gross  form  in  Barbados 
last  year  (1909),  and  I  was  the  means  of  drawing  attention  to  it, 
and  I  venture  to  hope  that  I  may  have  been  able  to  stop  it.  It 
arises  primarily  from  the  press  and  mercantile  community,  and 
these  agencies,  in  their  turn,  slowly  but  surely  influence  those 
in  authority  as  well  as  the  younger  members  of  the  medical 
profession. 

There  is  an  absolute  notification  fear.  I  have  known 
personally  medical  men  who  have  been  persecuted  because  they 
dared  to  notify  yellow  fever.  I  have  examined  the  correspon- 
dence in  other  cases,  where  the  medical  officer  making  the 
diagnosis  has  been  promptly  sat  upon,  and  where  in  consequence 
the  opinion  is  secretly  held  by  the  profession  that  it  was  better 
not  to  diagnose  yellow  fever.  This  year,  in  Africa,  the  press 
called  into  serious  question  the  diagnosis  of  the  reputable 
medical  authorities  of  the  Colony,  and  stoutly  upheld  and 
liberally  praised  those  who  diagnosed  "  bilious  remittent  fever." 

Press  vilification  is  common  all  over  the  world,  and  it  there- 
fore becomes  all  the  more  incumbent  upon  those  who  are  in 
administrative  authority  to  uphold  the  decision  of  their  medical 
officers.  I  will  give  three  examples  of  notification  fear  in 
West  Africa. 


NOTIFICATION  FEAR  321 

In  1884,  a  Dr  Davies,  practising  in  Freetown,  reported 
a  case  of  yellow  fever.  Upon  receipt  of  this  report,  the  acting 
principal  medical  officer  sent  him  a  letter,  asking  him  the 
grounds  upon  which  he  made  the  diagnosis,  and  if  "  he  con- 
sidered the  case  of  yellow  fever  which  he  had  had  in  his  practice 
to  be  contagious  or  not?"  In  a  letter  to  the  Governor  the 
acting  principal  medical  officer  stated  in  his  opinion  that  Dr 
Davies  had  made  a  grievous  mistake  in  his  diagnosis  of 
yellow  fever. 

In  1903,  a  Cape  Coast  doctor,  Dr  Barker,  wrote  the  acting 
principal  medical  officer  reporting  a  case  of  yellow  fever,  and 
stating  that  it  was  the  fifth  case.  The  medical  man  who  made 
this  diagnosis  was  Dr  Rome  Hall.  The  acting  principal 
medical  officer  wrote  as  follows  to  the  Colonial  Secretary  : — 
"  I  regret  to  say  that  I  am  obliged  to  take  the  alarmist 
statement  made  by  Dr  Rome  Hall  with  a  large  amount  of 
doubt." 

In  1910  there  is  an  improvement  as  regards  the  majority  of 
the  medical  officers,  who  all  have  had  the  courage  of  their  con- 
victions, and  did  not  hesitate  for  a  moment.  A  few  held, 
however,  that  the  disease  was  the  well-known  "  bilious  remittent 
fever,"  and  the  press  did  not  hesitate  to  openly  abuse  those  who 
diagnosed  yellow  fever. 

The  following  extracts  from  West  African  Coast  papers, 
serve  to  illustrate  this  extraordinary  notification  fear : — 

The  Alleged  Outbreak  of  Yellow  Fever  in  Secondee.    Extract 
from  the  "Gold  Coast  Leader,"  1910. 

"Since  we  asked  the  question  in  a  recent  issue  of  this  paper, 
whether  or  not  it  was  true  that  yellow  fever  existed  in  Secondee, 
events  have  transpired  there  of  great  importance  which  throw 
a  flood  of  light  upon  the  situation,  and,  before  setting  down  the 
facts,  we  may  at  once  relieve  the  mind  of  the  public  by  stating 
that  there  are  very  strong  grounds  for  believing  that,  in  all 
probability  the  cases  which  the  hospital  authorities  labelled  as 

X 


322  EARLY  NOTIFICATION,  ETC. 

yellow  fever  and  treated  as  such  were  not  cases  of  yellow  fever 

at  all." 

The  same  spirit  of  interference  of  the  press  in  matters  in 
which  they  can  have  little  real  knowledge  is  seen  in  the  follow- 
ing extract  from  the  Sierra  Leone  Weekly  News  of  4th 
January  1910 : — 

"  Nevertheless  there  is  a  disposition  on  our  part  to  beg  leave 
to  doubt  as  to  whether  the  cases  that  have  happened  are  cases 
of  real  yellow  fever,  or  of  what  may  be  termed  malignant 
malaria.  We  remember  something  of  this  kind  occasioning 
much  loss  of  life  among  the  European  portion  of  our  community 
to  have  happened  in  the  year  1884,  when  Rev.  E.  P.  Sparks, 
Colonial  Chaplain,  and  Mons  Criquet,  died,  and  the  community 
was  then  plunged  into  much  sorrow  on  their  account.  But  the 
expert  judgment  of  the  day  attributed  the  deaths  of  these 
Europeans,  not  to  yellow  fever,  but  to  what  they  called  malaria 
of  a  malignant  type. 

"  May  it  not  be  so  in  the  present  case  ?  We  cannot  of  course 
speak  confidently  on  the  subject,  not  being  experts,  but  we  have 
always  thought  that  a  case  of  actual  yellow  fever  is  invariably 
associated  with  black  vomit.  We  rather  lean  to  belief  in  the 
malarial  nature  of  the  disease,  because  the  present  season  of  the 
year  is  easily  conducive  to  malarial  developments.  We  are  just 
passing  from  the  dry  to  the  rainy  season  and,  in  the  passage, 
we  have  had  a  few  showers  which,  with  the  recurring  sunshine 
acting  upon  drains,  etc.,  may  easily  bring  to  pass  any  kind  of 
malaria." 

The  1884  outbreak  which  is  referred  to  in  the  above  was 
proved  to  be  one  of  typical  severe  yellow  fever  by  the  Com- 
mission, appointed  by  a  former  Governor,  Sir  Arthur  Havelock. 
There  can  be  no  doubt  that  the  wish  of  the  press  is  to  call  all 
fevers  malarial.  It  has  the  merit  of  not  leading  to  quarantine 
or  producing  a  scare.  But  it  has  a  disastrous  effect  in  the  lives 
of  the  whites. 

In  my  opinion,  the  injury  which  articles  of  this  nature  are 


DIFFICULTIES  323 

likely  to  produce  in  the  minds  of  the  poorer  and  more  ignorant 
classes  is  very  great.  A  real  injustice  is  done  to  the  sanitary 
reputation  of  the  colony,  and  the  good  name  of  the  colony  in 
other  directions  is  also  bound  to  be  affected. 

It  is  earnestly  to  be  hoped  that  a  more  healthy,  honest,  and 
mutually  co-operative  spirit  will  prevail  in  future,  and  that  the 
press  will  do  all  in  its  power,  by  means  of  reasoned  articles,  to 
show  the  world  how,  with  a  comparatively  small  outlay  of  money, 
the  unquestionably  unsavoury  reputation  of  the  Coast  for 
disease  is  quite  unnecessary  and  can  be  put  an  end  to,  to  the 
great  advantage  of  commerce  and  happiness. 

The  statement  which  I  have  made  in  my  work,  Health, 
Progress  and  Administrate  in  the  West  Indies,  upon  the 
obstacles  to  early  notification,  will  bear  repetition  in  this  place, 
because  they  are  applicable  to  what  has  happened  this  year, 
1910,  in  West  Africa.  I  wrote  under  the  heading  of  "Early 
Notification  :  Timidity,  Prejudice,  and  Opposition  "  : — 

"  As  in  my  British  Honduras  Report,  so  in  this  one,  I 
seriously  direct  attention  to  the  difficulties  of  early  notification. 

"  These  difficulties  have  been  encountered  in  an  aggravated 
form  in  British  Honduras  and  in  Central  and  Southern  American 
ports  generally.  There  is  no  question  in  my  mind  that  a 
considerable  amount  of  odium  is  liable  to  be  incurred  by  a 
medical  officer  who  has  the  courage  to  declare  a  case  of  yellow 
fever. 

"  This  unsatisfactory  state  of  affairs  is  often  owing  to  the 
fact  that  there  are  usually  to  be  found  medical  men  who, 
without  having  themselves  examined  a  particular  case,  never- 
theless make  up  their  minds  that  it  is  not  yellow  fever,  but 
some  other  simple  disease,  of  which  they  have  had  in  their 
practice  many  cases.  This  gives  the  press  an  opportunity,  if 
so  minded,  to  vilify  the  first  medical  officer  who  notifies,  and 
even  to  hint  that  he  knows  nothing  about  the  disease,  whilst  at 
the  same  time  lauding  the  particular  medical  man  who  has 
given  the  opinion  which  is  more  palatable,  and  therefore 
probably    more    in   accord  with  the   views   of  the   newspaper. 


324  EARLY  NOTIFICATION,  ETC. 

These  tactics  constitute  a  veiled  form  of  intimidation,  and  are 
destructive  in  the  long  run  to  the  reputation  of  any  colony  for 
fair  play  and  honesty. 

"  It  is  with  very  great  regret  that  I  am  obliged  to  state  that 
there  was  considerable  opposition  encountered  in  Barbados 
from  a  particular  section,  directed  to  thwarting  and  ridiculing 
those  who  were  acting  in  the  very  best  interests  of  the  community, 
by  insisting  upon  early  notification  of  suspected  cases." 


CHAPTER  XXI 

ANTI-MOSQUITO  ORDINANCES 

WITHIN  recent  years  an  attempt  has  been  made  to  grapple 
with  the  mosquito  nuisance  in  West  African  colonies,  just  as  I 
have  shown  has  been  done  in  the  case  of  the  West  Indian 
colonies  (see  Health  Progress  and  Administration  in  the  West 
Indies,  2nd  edition). 

Given  active  medical  officers  and  sanitary  inspectors,  a  great 
deal  can  be  done  at  a  comparatively  small  cost,  as  I  have 
witnessed  this  year  in  many  places  on  the  coast.  But  in  order 
to  accomplish  this,  the  medical  officer  has  to  take  upon  himself 
the  functions  of  sanitary  inspector  and  labourer.  In  other 
words,  he  has  to  do  the  cleaning  -  up  in  large  measure 
himself.  His  example  in  this  respect  is  of  immense  benefit 
to  the  Colony ;  for  the  European  merchants  and  the  natives 
soon  follow  suit,  and  begin  to  realise  that  it  is  not  beneath 
their  dignity  to  sweep  and  garnish  their  back  yards  and 
compounds. 

If  the  obvious  and  easily  removed  or  remedied  breeding- 
places  were  first  done  away  with,  an  immense  reform  would  be 
accomplished  for  a  very  little  expenditure  of  money.  It  would, 
moreover,  pave  the  way  for  the  other  improvement  schemes, 
such  as  water  supply  and  drainage.  For  a  coast  town  to 
proceed  with  elaborate  drainage  schemes,  whilst  each  compound 
is  left  to  swarm  with  easily  removed  breeding-places,  is  action 
which  displays  wanton  disregard  of  money,  as  well  as  ignorance. 
With    a    little    energy    and    a    little    kerosine    an    immense 

325 


326  ANTI-MOSQUITO  ORDINANCES 

breeding-ground  can  be  readily  removed,  and  a  corresponding 
improvement  in  the  health  guaranteed. 

In  Sierra  Leone,  a  special  ordinance  was  passed  to  deal  more 
specifically  than  in  the  old  Act  of  1905  with  mosquito  larvae. 

No.  16  of  1910 

An  Ordinance  to  Amend  the  Public  Health 
Ordinance,  1905 

Be  it  enacted  by  the  Governor  of  the  Colony  of  Sierra 
Leone,  with  the  advice  and  consent  of  the  Legislative  Council 
thereof,  as  follows  : — 

This  Ordinance  may  be  cited  as  the  Public  Health  Amend- 
ment Ordinance,  1910. 

Notwithstanding  anything  to  the  contrary  contained  in  the 
Public  Health  Ordinance,  1905  (hereinafter  called  the  Principal 
Ordinance),  where  mosquito  larvae  are  found  by  the  Sanitary 
Authority  in  any  collection  of  water  or  in  any  well,  pool, 
channel,  barrel,  tub,  bucket,  or  any  other  vessel  in  any 
premises,  the  occupier  or  owner  in  occupation  of  the  premises 
on  which  the  nuisance  arises  shall  be  liable  on  summary  convic- 
tion to  a  fine  not  exceeding  Twenty  shillings  for  each  offence, 
whether  any  such  notice  requiring  abatement  of  nuisance  or 
nuisance  order,  as  is  in  the  Principal  Ordinance  mentioned,  is 
or  is  not  served  or  made  upon  him. 

This  Ordinance  shall  be  brought  into  operation  by  the 
Governor-in-Council  by  Order  from  time  to  time,  and  it  shall 
be  lawful  for  the  Governor-in-Council  by  such  Order  to  apply 
this  Ordinance  or  any  part  thereof  to  any  town  or  village 
or  part  of  a  town  or  village  of  the  Colony,  with  or  without 
conditions. 

Nothwithstanding  the  provisions  of  Section  3,  this  Ordinance 
shall,  until  otherwise  ordered  by  the  Governor-in-Council,  apply 
to  the  City  of  Freetown,  subject  to  the  proviso  that  no 
proceedings  under  the  provisions  of  section  2  hereof  shall  be 
taken  in  respect  of  mosquito  larvae  found  by  the  Sanitary 
Authority  in  any  well,  pool,  or  channel  in  rock  or  earth  till  the 
same  have  been  ordered  by  a  further  Order  of  the  Governor-in- 


NIGERIA  327 

Council :  And  subject  to  the  further  proviso  that  nothing  in 
this  section  or  in  this  Ordinance  shall  prevent  any  proceedings 
being  taken  in  respect  of  the  nuisances  liable  to  be  dealt  with 
summarily  under  the  Principal  Ordinance  or  for  the  penalties 
imposed  by  the  Ordinance,  on  account  of  the  existence  of  such 
nuisances. 

Southern  Nigeria. — A  special  mosquito  destroying  ordinance 
was  passed  4th  August  1910. 

It  shall  not  be  lawful  for  any  owner  or  occupier  to  allow  at 
any  time  the  presence  on  his  premises  of  any  receptacle  for 
water  containing  mosquito  larvae,  or  to  allow  any  water  to  be 
kept  on  his  premises  for  a  period  exceeding  three  days  without 
the  receptacle  containing  the  same  being  emptied  and  cleaned, 
unless  such  receptacle  is  properly  protected  or  screened,  to  the 
satisfaction  of  the  Sanitary  Authority,  from  the  access  of 
mosquitos,  nor  shall  such  owner  or  occupier  allow  on  his 
premises  any  reasonably  preventable  conditions  which  may, 
in  any  way,  be  favourable  to  the  breeding  of  mosquitos. 

It  shall  be  lawful  for  the  Sanitary  Authority  to  recover  from 
the  owner  or  occupier  of  any  premises  the  expense  of  any 
measures  carried  out  on  his  premises  under  the  provisions  of 
this  Ordinance,  but  if  it  is  satisfied  that  such  owner  or  occupier 
is  not  in  a  position  to  pay  such  expenses,  to  pay  all  such 
expenses  itself. 

All  expenses  incurred  by  the  Sanitary  Authority  in  carrying 
out,  with  respect  to  any  premises,  the  provisions  of  this 
Ordinance,  shall  and  may  be  recovered  in  a  summary  manner 
before  a  Police  Magistrate  or  District  Commissioner,  anything 
in  the  Supreme  Court  Ordinance  to  the  contrary  notwith- 
standing. 

Any  person  who  obstructs  the  Health  Officer,  or  any 
Medical  Officer  specially  appointed  by  the  Governor  for  the 
purpose,  the  Sanitary  Engineer,  Sanitary  Inspector,  or  any 
person  duly  deputed  in  writing  by  the  Health  Officer  to  carry 
out  the  provisions  of  this  Ordinance  in  any  act  authorised  by 
this  Ordinance  shall  be  liable  to  a  fine  not  exceeding  twenty- 
five  pounds,  or  in  default  thereof  to  imprisonment  not  exceeding 
three  months. 


328  ANTI-MOSQUITO  ORDINANCES 

(i.)  Any  person  who  contravenes  any  of  the  provisions  of 
Section  4  of  this  Ordinance  shall  be  liable  to  a  fine  not 
exceeding  five  pounds  or  in  default  to  imprisonment  not 
exceeding  one  month. 

Gold  Coast  Colony. — Under  Section  18  of  the  Infectious 
Disease  Ordinance,  1908,  regulations  were  made  to  deal  with 
the  outbreak  of  yellow  fever  in  Secondee.  They  were  issued 
17th  May  1910,  and  the  clauses  dealing  with  mosquitos  are  as 
follows : — 

The  Senior  Sanitary  Officer,  Medical  Officer  of  Health,  a 
Medical  Officer,  the  Commissioner  of  the  Western  Province, 
District  Commissioner,  or  any  person  authorised  by  any  one  of 
them,  may  enter  upon  any  land,  house,  or  premises  in  Secondee 
for  any  of  the  following  purposes  : — 

(i.)  To  inspect  all  water  receptacles    therein    and   destroy, 
repair,  or  otherwise  deal  with  such  as  are  not  mosquito 
proof,  or  form  or  may  form  breeding-places  for  mosquitos, 
and  treat  the  water  therein  with  kerosene. 
(ii.)  To  fill  up  or  otherwise  deal  with  all  pools,  holes,  wells 
and  other  places,  where  there  is  standing  water  which 
are  or  may  become  breeding-places  for  mosquitos.   - 
(iii.)  To  make  such  alterations  to  the  roof  or  gutters  of  any 
house  or  building  to  prevent  stagnant  water  remaining 
therein, 
(iv.)  To  clear  and  clean  such  premises  of  all  rubbish  tins, 

bottles,  and  undergrowth, 
(v.)  Generally  to  take  all  such  steps  as  may  be  necessary  to 
destroy  and   prevent  the  breeding  of  mosquitos  upon 
any  such  premises. 
The  provisions  of  this  Order  shall  be  published  by  beating 
of    gong    within   the   said    Municipal   Area    by   the   chiefs    of 
Secondee.     Made  by  the  Governor-in-Council  this  17th  day  of 
May  1910. 

The  Gambia. — The  Public  Health  Ordinance  of  1910  has 
been  modified  to  lay  greater  stress  upon  mosquitos,  insects,  and 
parasites  as  follows  : — 

(a)  All  collections  of  water,  sewage,  rubbish,  refuse,  ordure,  or 


GAMBIA  329 

other  fluid  or  substance,  and  all  other  conditions  which  permit 
or  facilitate,  or  are  likely  to  permit  or  facilitate,  the  breeding 
or  multiplication  of  animal  or  vegetable  parasites  of  men 
or  domestic  animals,  or  of  insect  or  other  agents  which  are 
known  to  carry  such  parasites,  or  which  may  otherwise  cause 
or  facilitate  the  infection  of  men  or  domestic  animals  by  such 
parasites. 

(J?)  Any  collection  of  water  in  any  well,  pool,  channel, 
depression,  excavation,  barrel,  tub,  bucket,  or  any  other  vessel, 
and  found  by  the  Board  to  contain  mosquito  larvae. 

'(c)  Any  cesspool,  privy,  urinal,  dung-pit,  ash-pit,  found  by 
the  Sanitary  Authority  to  contain  mosquito  larvae  shall  be 
nuisances  liable  to  be  dealt  with  summarily  under  this 
Ordinance. 

The  occupier  or  owner  of  any  premises  shall  keep  such 
premises  free  from  all  articles,  bottles,  whole  or  broken,  whether 
fixed  on  walls  or  not,  old  tins,  boxes,  calabashes,  earthenware 
vessels,  shells,  or  any  other  articles  which  may  retain  water,  and 
so  become  the  breeding-place  of  mosquitos.  Any  occupier  or 
owner  of  any  premises  failing  to  comply  with  the  provisions  of 
this  section  shall  be  liable  to  a  fine  not  exceeding  twenty 
shillings. 

Any  person  who  shall  keep  on  any  premises  any  collection 
of  water  in  any  well,  barrel,  tub,  bucket,  tank,  or  any  other 
vessel  intended  for  the  storage  of  water  without  providing  them 
with  covers  so  constructed  as  to  prevent  the  ingress  of  mosquitos 
into  the  same,  shall  be  liable  to  a  fine  not  exceeding  twenty 
shillings.  If  a  person  shall  fail  to  comply  with  the  provisions  of 
this  section  he  shall,  after  notice  received  from  the  Sanitary 
Authority  to  comply  therewith,  be  liable  to  a  further  fine  not 
exceeding  twenty  shillings  a  day  during  his  default. 

On  the  receipt  of  any  information  respecting  the  existence 
of  a  nuisance  liable  to  be  dealt  with  summarily  under  the 
preceding  sections  (A,  B,  and  C)  of  this  Ordinance,  the  Board 
shall,  if  satisfied  of  the  existence  of  such  a  nuisance,  serve  a 
notice  on  the  person  by  whose  act,  default,  or  sufferance  the 
nuisance  arises  or  continues,  or  if  such  person  cannot  be  found, 
on  the  occupier  or  owner  of  the  premises  on  which  the  nuisance 
arises,  requiring  him  to  abate  the  same  within  the   specified 


330  ANTI-MOSQUITO  ORDINANCES 

time  by  such  notice,  and  to  execute  such  works  and  do 
such  things  as  may  be  necessary  for  that  purpose,  and  if  the 
Board  think  it  desirable  (but  not  otherwise)  specifying  the 
works  to  be  executed. 

The  Board  may  also  by  the  same  or  another  notice,  served 
on  such  occupier,  owner,  or  person,  require  him  to  do  what  is 
necessary  for  preventing  the  recurrence  of  the  nuisance,  and,  if 
it  think  it  desirable,  specify  any  works  to  be  executed  for  that 
purpose,  and  may  serve  that  notice  notwithstanding  that  the 
nuisance  may  from  the  time  have  been  abated,  if  the  Board 
consider  that  it  is  likely  to  recur  on  the  same  premises  provided 
that  where  mosquito  larvae  are  found  in  any  collection  of  water, 
or  in  any  well,  or  pool,  channel,  barrel,  tub,  bucket,  tank,  or  any 
other  vessel,  or  in  any  bottle,  whole  or  broken,  whether  fixed  on 
a  wall  or  not,  tin,  box,  calabash,  shell,  or  any  other  article,  the 
Board  itself  may  abate  the  same,  and  may  do  what  is  necessary 
to  prevent  the  recurrence  thereof. 

All  cesspits  shall  be  so  screened  as  to  prevent  the  ingress  of 
mosquitos,  or  alternatively  shall  be  covered  with  oil  or  other 
approved  larvicide  at  least  once  a  week.  The  occupier  or  owner 
of  any  premises  to  which  any  cesspit  not  treated  in  accordance 
with  the  provisions  of  this  section  is  attached  shall  be  liable  to 
a  fine  not  exceeding  twenty  shillings. 

The  Board  may  by  a  general  order  prohibit : 

(a)  the  making  of  holes,  pits,  or  excavations,  for  the  purpose 

of  taking   earth  from  them  or  of  storing   rubbish   or 
offensive  matter  therein  ; 

(b)  the  digging  of  cesspools,  tanks,  wells,  or  pits,  without 

special  sanction. 

If  any  such  excavation,  tank,  well,  or  pit  is  made  after  the 
publication  of  any  such  order,  and  without  the  permission 
required  thereby,  the  Board  may  by  written  notice  require  the 
owner  or  occupier  of  the  land  on  which  the  same  is  made  to  fill 
up  the  same  with  earth  or  other  material  approved  by  them. 

If  default  be  made  in  complying  with  such  notice  the  Board 
may  cause  the  work  to  be  executed  and  half  the  expenses 
thereby  incurred  shall  be  paid  by  the  owner  and  half  by  the 
occupier  of  the  land. 


TOGOLAND  331 

The  Anti-mosquito  Decree,  Togoland,  1910 

1.  All  receptacles  for  storing  water  must  be  furnished  with  a 
mosquito  proof  covering,  or  they  must  be  emptied  every  four 
days  at  least,  in  order  to  prevent  the  development  of  mosquito 
larvae.  Instead  of  screening,  a  larvicide  like  petroleum  may 
be  added  to  the  water.  Boats  may  be  treated  in  a  similar 
manner. 

2.  Odd  receptacles  in  which  water  may  collect  such  as  tins, 
bottles,  etc.  (boats  and  "  Einbauma  "  excepted),  are  to  be  kept  in 
such  a  manner  .that  water  cannot  collect  in  them  ;  pools  of  water 
must  not  be  allowed  to  remain  for  longer  than  twenty-four  hours. 
The  decrees  respecting  deposits  of  refuse  remain  unaltered. 

3.  On  the  request  of  the  local  authorities  waste  ground  and 
other  uncultivated  plots  are  to  be  freed  from  bush,  which  may 
serve  as  cover  for  mosquitos. 

4.  The  Medical  Officer  and  the  Inspector  employed  by  the 
local  authorities  are  authorised  to  inspect  grounds  and  localities 
for  the  purpose  of  sanitary  surveyance  at  any  hour  of  the  day, 
alone,  or  accompanied  by  the  Sanitary  Inspectors. 

The  Sanitary  Inspectors  alone  are  authorised  to  do  so  only 
on  certain  days  and  at  certain  hours  which  are  to  be  fixed  by 
the  "  Medical  Officer,"  or  the  local  authorities  and  which  must 
be  made  public.  The  official  notification  appears  quarterly  in 
the  Amtsblatt)  and  at  least  once  a  week  before  the  beginning  of 
the  period  in  question. 

The  owners  of  the  lots  have  to  submit  to  the  required 
measures  necessary  for  the  sanitary  surveyance. 

5.  Non-natives  failing  to  comply  are  liable  to  a  fine  not 
exceeding  100  marks,  or  two  weeks'  imprisonment.  In  the  case 
of  natives,  however,  the  fine  will  be  according  to  the  decree  of 
the  Governor  of  22nd  April  1896  {Kol.  Blatt,  p.  241). 

In  cases  of  failure  to  comply  with  clauses  1  or  2,  fines  will  be 
imposed : 

(a)  On  the  owner  of  the  receptacles  named  under  clause 
1,  or  on  anyone  who  has  not  complied  with  the  condi- 
tions of  clause  2. 

(J?)  If  the  occupier  {a)  cannot  be  found  out,  or  his  punish- 
ment is   not  possible  for  some  other  reason,  then  the 


332  ANTI-MOSQUITO  ORDINANCES 

owner  of  the  grounds  on  which  the  nuisance  has 
occurred  is  liable  to  prosecution. 
(c)  If  the  owner  of  the  property  cannot  be  found  or  his 
punishment  is  not  possible  for  some  other  reason,  then 
the  agent  of  the  owner  or  the  administrators  are  liable 
to  prosecution. 

6.  This  decree  comes  into  force  on  ist  July  1910. 

Enforcement  of  anti-mosquito  laws. — The  preceding  laws  and 
regulations  are  very  good  on  paper,  but  unless  they  are  backed 
up  by  daily  inspections  by  the  sanitary  inspectors  and  medical 
officers,  and  unless  the  inhabitants  who  may  offend  are  quickly 
brought  to  book  for  offences  under  them,  they  are  of  course, 
useless.  During  the  outbreak  of  yellow  fever,  1910,  the  senior 
sanitary  officer  in  Secondee  took  summary  action  with  good 
effect,  and  fines  were  likewise  inflicted.  In  Nigeria  the  passing 
of  the  Ordinance  was  viewed  with  great  disfavour,  by  one  section 
of  the  press,  which  indulged  in  the  following  mediaeval  garbage, 
by  way  of  comment  on  the  Ordinance.  From  The  Nigerian 
Times,  5th  July  19 10: — 

"  But  we  might  ask  the  question  whether  the  Government 
realises  that  the  task,  the  performance  of  which  it  has  under- 
taken under  this  Ordinance,  is  one  which  is  really  superhuman. 
First  of  all  the  Government  ought  to  be  aware  that  mosquitos 
do  not  breed,  nor  do  they  propagate  in  the  sense  that  we  under- 
stand the  propagation  of  species.  The  larvse  are  generated  by 
some  atmospheric  action  on  water — fresh-water  especially — 
under  certain  climatic  conditions  and  influences,  more  particu- 
larly at  certain  seasons,  operating  on  the  oxygen  or  some  other 
of  the  constituents  of  fresh-water ;  and  the  larvse  develop  into 
mosquitos.  We  do  not  profess  to  give  this  as  a  scientific 
description,  nor  would  we  allege  that  the  statement  is  founded 
on  accurate  scientific  knowledge.  The  statement  is  neverthe- 
less an  accurate  description  of  certain  processes  which  are  to  be 
seen  going  on  under  ordinary  observation  daily.  So  that 
whether  the  '  receptacle  in  which  water  is  stored  is  properly 
protected   or  screened  from  the  access  of  mosquitos,'  the  larvse 


PROSECUTIONS  333 

can  and  do  oftentimes  generate  in  the  water  so  protected  or 
screened,  and  develop  into  mosquitos  on  any  occasion  of  a 
contact  for  a  short  period  with  the  influences  of  the  external 
atmospheric  action." 

I  have  repeatedly  pointed  out  the  existence  of  this  mediaeval 
superstition  in  the  newspapers  of  British  tropical  colonies.  It 
demonstrates  that  ignorance  of  simple  biological  facts  is  still  a 
nightmare  to  overcome  in  West  Africa.  Moreover,  if  the 
ignorance  of  simple  facts  is  so  obvious  in  this  direction,  we  may 
be  certain  that  ignorance  in  the  other  directions  which  make  for 
the  progress  and  welfare  of  the  colony  is  equally  great. 

In  my  opinion,  formed  as  the  result  of  my  various  investiga- 
tions in  tropical  countries  far  more  stress  requires  to  be  laid 
upon  educating  the  people  both  young  and  old.  In  Sierra 
Leone,  thanks  to  this  far-seeing  initiative  of  Sir  Leslie  Probyn, 
a  great  deal  has  been  accomplished  in  this  direction.  In  the 
Gold  Coast  Colony  the  late  Sir  John  Rodger  has  also  sown  good 
seed. 

Prosecutions  under  the  Mosquito  Ordinances 

In  Freetown,  from  April  to  July,  thirty-nine  convictions  were 
obtained  for  having  larvae  on  premises  and  for  other  offences 
under  the  Health  Act;  fines  to  the  total  of  £n,  6s.  yd.  were 
inflicted. 

In  Secondee  from  May  up  till  June  1910,  thirty-two  convic- 
tions were  obtained  and  fines  inflicted  to  the  total  of  £39. 

In  Accra  there  were  several  convictions  and  fines  from  10s. 
to  £1  were  inflicted. 


CHAPTER   XXII 

.TOWN    PLANNING   AND   SEGREGATION — MINING 
AND   RAILWAY  WORKS 

Systematic  inspection  of  the  sickness  and  mortality  returns  of 
the  West  African  colonies,  which  are  published  in  the  annual 
medical  and  sanitary  returns  of  the  various  colonies,  shows 
most  unmistakably  that  the  merchant  and  non-official  classes 
are  at  a  disadvantage  compared  to  the  official  classes  both  as 
regards  sickness  and  mortality  rates.  These  points  are  well 
brought  out  in  the  following  returns  prepared  for  Secondee 
on  the  Gold  Coast : — 


Year. 

Died. 

Invalided. 

Death-Rate. 

Invaliding 
Rate. 

OFFICIALS. 

1906 

I 

21 

1.8 

39.6* 

1907 

I 

I 

07 

3-9 

1908 

O 

II 

nil 

5-9 

1909 

O 

IO 

nil 

16-12 

NON-OFFICIALS. 

1906 

3 

II 

40 

148-0 

1907 

3 

IO 

18 

62-0 

1908 

3 

12 

22 

88-o 

1909 

2 

7 

13-3 

46-6 

*  Three  included  from  up  country. 


Commenting   upon  these  figures  the  senior  sanitary  officer 
of  the  Gold  Coast  states  as  follows  : — "  A  study  of  the  compara- 

334 


FlG.  56. — Coolie  Ranges  on  each  side  of  Wide  Road,  Trinidad. 


[To  face  -p.  834. 


SEGREGATION  335 

tive  death  and  invaliding  rates  of  the  European  officials  and 
non-officials  in  Secondee  from  the  years  1906  to  1909  affords  an 
interesting  object-lesson  on  the  value  of  segregation,  when  it 
is  borne  in  mind  that  the  officials  are  segregated,  the  non- 
officials  not. 

Invaliding  rate  of  Officials  per  1000     .         .        .  16-38 

Invaliding  rate  of  Non-officials  per  1000      .        .  86-1 
Death-rate  of  Officials  per  1000    ....  0-52 

Death-rate  of  Non-officials  per  1000    .  .  23-33 

"  In  a  report  on  Secondee,  written  in  April  1910,  I  stated 
that  '  experience  has  taught  us  that  Europeans  who  reside  in 
West  Africa  unsegregated  from  natives,  have  a  high  sickness 
and  death-rate.'  This  experience  has  been  added  to  by  the 
recent  outbreak  of  yellow  fever  in  Secondee." 

"  When  one  reflects  that  probably  not  one  of  the  valuable 
lives  sacrificed  in  the  recent  outbreak  would  have  been  lost  had 
the  European  merchants  lived  like  the  officials,  segregated  from 
the  natives,  the  value  and  paramount  necessity  of  practising 
segregation  in  this  country  is  impressed  in  one's  mind.  I  am 
aware  that  public  opinion  is  not  yet  ripe  for  the  consideration  of 
compulsory  segregation  ;  but  I  look  forward  to  the  day  when 
it  will  be,  and  when  the  fact  will  be  recognised  that  the  natives 
of  West  Africa  are  so  many  reservoirs  of  disease  to  which  they 
themselves  are  comparatively  immune,  but  which,  when  mosquito- 
borne  to  the  Europeans,  are  capable  of  producing  fatal  results. 
Under  present  conditions  it  is  as  dangerous  to  live  unsegregated 
from  the  natives  in  West  Africa  as  it  is  to  live  in  the  immediate 
vicinity  of  a  small-pox  hospital  in  England,  but  the  former 
practice  is  tolerated,  the  latter  not.  In  the  meantime  it  will 
be  necessary  to  largely  increase  the  number  of  scavengers 
employed  and  the  sanitary  staff,  in  order  to  wage  a  constant 
war  on  mosquito-breeding  vessels  and  areas.  I  advise,  too, 
that  the  special  anti-larval  powers  given  to  the  sanitary 
authorities  in  Secondee  during  the  outbreak  of  yellow  fever 
be  made  to  apply  all  over  the  Colony." 


336     TOWN  PLANNING,  SEGREGATION,  MINING,  ETC. 

With  the  statement  contained  in  the  preceding  paragraphs 
I  heartily  agree. 

The  cause  of  the  ominous  difference  between  the  two  classes 
is  not  far  to  seek.  Principal  medical  officers  have  over  and 
over  again  drawn  attention  to  it.  Governors  have  also  done 
their  best  to  impress  upon  the  mercantile  classes  that  this 
difference  does  exist.  But  in  spite  of  all  warnings  little 
endeavour  is  made  to  remedy  the  evil.  The  reason  for  this  is 
of  course  not  far  to  seek.  The  medical  officer  and  the  adminis- 
trator points  out  that  as  the  result  of  the  most  recent  and  well- 
established  researches  in  medicine,  there  can  be  no  question 
that  certain  diseases  like  malaria  and  yellow  fever  are  endemic 
amongst  the  native  races,  and  that  in  consequence  the  first 
measure  of  protection  which  the  newcomer  should  naturally 
take,  would  obviously  be  to  sleep  in  some  locality  removed  from 
the  native  houses. 

On  the  other  hand,  a  short-sighted  financial  policy  on  the 
part  of  the  mercantile  firms,  argues  that  it  would  place  the 
white  traders  at  a  disadvantage  if  they  resided  at  a  distance 
from  their  place  of  business. 

It  will  perhaps  be  remembered  that  precisely  the  same 
arguments  were  held  in  Europe  from  the  Middle  Ages  up  to 
the  nineteenth  century.  Merchants  in  olden  times  lived  over 
their  shops,  no  doubt  to  keep  guard  over  their  goods  and  money. 
But  the  practice  had  to  be  given  up  because  it  was  obviously 
insanitary. 

At  the  present  day  in  West  Africa  it  is  not  necessary  for 
the  business  clerks  and  managers  to  reside  in  business  houses 
in  the  midst  of  native  houses.  During  the  daytime  the  business 
can  be  transacted  in  the  store,  but  at  night-time  the  clerks  and 
managers  could  readily,  were  quarters  provided  for  them,  sleep 
some  distance  away  from  the  native  town. 

Observation  has  taught  us  that  risk  of  infection  during  the 
day  is  far  less  than  at  night.  Business  can  be  carried  on  with 
comparative  safety  in  the  towns  during  the  daytime,  because 


FlG.  57. — A  Road  in  Port  of  Spain,  properly  graded,  with  well-made  concrete  side  drains. 


[To  face  p.  336. 


SEGREGATION  337 

daylight  and  currents  of  air  afford  a  very  considerable  measure 
of  safety  against  mosquito-carried  diseases. 

On  the  other  hand,  it  has  been  proved  in  innumerable 
instances  that  those  traders  who  have  lived  on  their  business 
premises  amongst  the  native  houses,  and  especially  those  who 
have  been  obliged  to  live  in  badly  constructed  houses  and  on 
the  ground  floor,  have  almost  without  exception  contracted  some 
form  of  endemic  disease.  Surgeon-general  Blair  drew  attention 
to  this  fact  in  Georgetown,  British  Guiana,  and  during  the 
recent  epidemic  (1910)  of  yellow  fever  along  the  West  Coast,  it 
has  been  most  observable  that  the  white  residents  who  lived 
in  the  midst  of  the  native  inhabitants  were  the  first  to  contract 
yellow  fever,  whilst  those  who  lived  some  distance  away  were 
not  affected. 

Thus  the  Hill  Station  in  Freetown  afforded  complete  pro- 
tection to  its  inhabitants.  On  the  other  hand,  it  is  very 
significant  that  in  Freetown  itself  the  first  whites  to  become 
infected  with  yellow  fever  were  the  Syrian  traders  living  in  the 
dense  native  quarters  of  the  town. 

These  traders  live,  as  is  well  known,  with  their  families  in 
small  houses  wedged  in  amongst  the  native  houses.  Their 
sleeping  and  living  rooms  are  often  on  the  ground  floor,  or  at 
most  only  slightly  elevated  from  the  ground  level. 

The  Stegomyia  is  breeding  everywhere  in  immense  numbers 
immediately  around  them,  and  can  readily  gain  access  to  their 
sleeping  and  living  rooms.  Therefore  the  fact  that  the  small 
Syrian  traders  first  demonstrated  the  existence  of  yellow  fever 
in  Freetown,  is  precisely  what  one  would  expect  in  a  place 
where  we  have  every  reason  to  believe  yellow  fever  is 
endemic. 

Had  it  broken  out  at  the  Hill  Station  or  in  the  military 
quarters  placed  in  well-elevated  sites  above  the  town,  it  would 
have  been  a  matter  of  very  great  surprise.  It  did  not  do  so, 
and,  as  has  been  demonstrated  on  countless  occasions  in  the 
past,  segregation  afforded  the  necessary  protection. 

Y 


338    TOWN  PLANNING,  SEGREGATION,  MINING,  ETC. 

But  in  spite  of  this  fact  being  fully  accepted  all  over  the 
tropical  world  as  a  well-established  axiom  in  yellow  fever, 
firms  still  pay  little  attention,  and  will  not  take  the  opportunities 
held  out  to  them  by  Colonial  governments  to  select  suitable 
sites,  removed  a  short  distance  from  the  native  houses. 

The  Gold  Coast  Government  announced  in  1908  that  it  was 
prepared  to  lease  land  close  to  Accra  for  a  term  of  fifty  years 
at  a  very  reasonable  price  for  the  erection  of  bungalows,  built 
on  an  approved  plan. 

It  was  stipulated  that  the  only  natives  to  reside  on  the 
premises  were  to  be  the  personal  servants  of  the  residents. 

The  bungalows  and  grounds  were  to  be  subjected  to 
periodical  inspection  by  the  medical  authorities. 

Thus  both  at  Accra  and  Freetown  every  inducement  has 
been  held  out  to  the  white  non-immune  to  reside  outside  the 
danger  zone ;  but  exceedingly  few  have  taken  advantage  of 
these  offers.  Many  still  reside  in  the  closest  proximity  to 
the  native  houses,  and  criticise  the  administration  because 
their  sickness  and  mortality  rate  is  high. 

The  question  of  town  planning  is  now  likely  to  assume  a 
practical  form  in  view  of  the  increasing  prosperity  of  West 
Africa. 

This  will  afford  an  excellent  opportunity  to  bring  about 
segregation  from  the  very  outset,  by  reserving,  as  has 
already  been  done  at  Bo  in  the  Sierra  Leone  Protectorate,  a 
portion  of  the  town  for  the  white  traders. 

At  the  same  time  care  can  be  taken  that  the  streets  are  of 
suitable  width,  and  that  none  of  the  glaring  disadvantages  of 
existing  native  towns  are  repeated. 

In  conclusion,  I  would  place  segregation  of  the  whites  (non- 
immunes) in  the  fore-rank  of  all  prophylactic  measures  at  the 
present  time  in  West  Africa.  It  is  practicable  and  can  be 
carried  out  at  once. 

Drainage  operations  and  anti-mosquito  measures  generally 
require  a  little  time  and    organisation   before   results   can  be 


SEGREGATION  339 

seen.  This  is  readily  understood  by  those  who  have  practical 
knowledge  of  West  African  towns. 

The  merchant  at  home  in  England  does  not  live  in  the 
slums,  why  should  he  expect  his  clerks  to  do  so  in  West  Africa, 
where  they  are  exposed  to  far  greater  risks  owing  to  the 
prevalence  of  endemic  diseases. 

The  saving  in  invaliding  pay  would  alone  compensate  for 
any  supposed  disadvantage  of  sleeping  a  short  distance  from 
the  native  quarters. 


CHAPTER  XXIII 

YELLOW  FEVER  PROPHYLAXIS  IN  WEST  AFRICA,  1906  AND  I9IO 

BEFORE  discussing  in  detail  routine  yellow  fever  prophylaxis, 
I  wish  to  draw  the  reader's  attention  to  what  was  done  this 
year,  and  also  in  1906  to  prevent  the  spread  of  yellow  fever. 
It  is  a  very  practical  lesson  and  serves  as  an  admirable  guide 
for  future  occasions. 

In  the  first  place,  owing  to  a  variety  of  circumstances 
on  the  West  African  Coast,  the  medical  men  were  not  on 
the  lookout  for  yellow  fever.  When  on  12th  May  the  medical 
officer  at  Secondee  was  convinced  that  he  was  face  to  face 
with  yellow  fever,  owing  to  the  fact  of  the  occurrence  of 
three  cases  exhibiting  the  clinical  features  of  yellow  fever,  not 
a  moment  of  time  was  lost.  The  greatest  praise  is  due  to  all 
the  medical  officers,  for  their  exceedingly  prompt  and  fearless 
action  in  this  connection. 

On  13th  May  the  Port  of  Secondee  was  declared  infected. 

On  14th  May  the  senior  sanitary  officer  arrived  to  take 
charge  of  the  preventive  measures,  and  brought  with  him  a 
Clayton  sulphur  apparatus  and  a  supply  of  sulphur. 

Two  important  movements  were  set  on  foot,  both  of  which 
were  based  upon  the  principle  of  segregation  of  the  non- 
immunes. 

Step  1,  taken  on  15th  May,  consisted  in  deflecting  the  traffic 
from  the  infected  town  of  Secondee  to  another  point  on  the 
coast  1 1  miles  distant,  where  the  ships  could  call.  Secondee  is 
the  principal  port  for  the  mining  centres,  and  is  the  point  of 

340 


FlG.  58. — The  "  Bee  Hive  Destructor."      A  very  simple,  efficient,  and  cheap  form  of 
destructor,  constructed   out  of  "swish."       Secondee,  Gold  Coast. 


[To  face  p.  340. 


FIRST  STEPS  341 

departure  of  the  railway  system,  and  under  ordinary  circum- 
stances there  is  a  constant  flow  of  non-immune  whites  to  and 
from  the  mines  to  the  steamers.  Therefore  the  senior  sanitary 
officer  deflected  the  railway  passengers  at  a  place  on  the  railway 
9  miles  above  Secondee,  and  arranged  for  their  transport  to  a 
small  village  on  the  coast,  especially  prepared  for  their  recep- 
tion 1 1  miles  distant  along  the  coast  from  Secondee.  The  non- 
immunes were  safe  from  the  risk  of  infection  in  this  village, 
and  were  most  carefully  supervised.  It  served  as  an  observa- 
tion or  detention  camp  for  travellers  in  transit,  and  there  being 
no  yellow  fever  there,  the  ships  called,  and  trade  with  the 
mining  centres  was  inconvenienced  as  little  as  possible. 

Step  2  consisted  on  15th  May  in  issuing  instructions  to 
prepare  temporary  sleeping  accommodation  for  all  those  white 
traders  in  Secondee  who  had  not  a  residence  outside  of  the 
town  area.  A  temporary  camp  was  chosen  on  an  elevated 
site  at  a  reasonable  distance  from  the  town.  On  the  same  day 
a  public  meeting  was  called  of  the  residents,  and  the  nature  of 
the  outbreak  and  the  preventive  measures  contemplated  were 
fully  explained.  At  the  same  time,  all  Europeans  residing  in 
the  infected  business  area  were  notified  that  from  5  P.M.  on 
17th  May,  Europeans  would  only  be  allowed  within  the  infected 
area  between  the  hours  of  7  A.M.  and  8  P.M.  In  other  words, 
the  non-immunes  were  obliged  to  sleep  outside  the  infected 
area.  After  these  immediate  emergency  steps  were  taken,  the 
senior  sanitary  officer  proceeded  to  organise  the  sanitary  forces 
at  his  disposal,  to  enrole  volunteers,  and  to  proceed  to  execute 
the  well-known  anti-Stegomyia  measures  of  larval  destruction, 
and  the  systematic  fumigation  of  all  houses  in  the  infected 
quarter.  Before  proceeding  to  describe  these  steps,  it  is 
interesting  to  compare  the  steps  which  the  French  medical 
authorities  took  in  1906,  on  the  outbreak  of  yellow  fever  at 
Bamako,  in  Senegal. 

1.  The  first  step  consisted  in  an  official  notification  of  the 
danger. 


342    YELLOW  FEVER  PROPHYLAXIS  IN  WEST  AFRICA 

2.  Secondly  the  medical  men  were  summoned  together  to 
discuss  the  situation. 

3.  Sanitary  forces  were  organised,  and  a  raid  made  upon 
the  breeding  grounds  of  the  Stegomyia. 

4.  A  temporary  camp  was  constructed  at  a  distance  from 
the  infected  town,  where  the  non-immunes  were  obliged  to  retire 
from  sunset  to  sunrise.  This  was  enforced  for  twenty  nights. 
Goods  and  provisions  for  the  use  of  the  camp  were  packed 
during  the  daytime. 

Is  is  very  noteworthy,  therefore,  that  both  the  French  and 
English  medical  authorities  put  the  removal  of  the  non- 
immunes in  the  first  line  of  defence.  This  is,  in  my  opinion, 
the  right  course.  Remove  to  a  place  of  safety  the  vulnerable, 
i.e.,  enforce  temporary  segregation  until  all  the  houses  in  the 
infected  quarter  are  fumigated,  and  all  infected  Stegomyia  are 
destroyed.  In  both  instances  absolute  success  followed  these 
measures.  Where  these  precautions  are  not  taken — I  can  speak 
with  experience — yellow  fever  lingers  on.  To  continue  with  the 
prophylactic  measures  which  were  undertaken  at  Secondee — 

On  1 8th  May,  mosquito  brigades  were  organised.  The 
emergency  temporary  buildings  erected  consisted  of : — 

1.  A  mosquito-protected  hospital  for  Europeans. 

2.  Accommodation  for  European  contacts. 

3.  Mosquito-proof  hospital  for  natives. 

4.  Buildings  for  Syrians. 

5.  Buildings  for  segregating  natives  wishing  to  leave 
Secondee. 

6.  Buildings  for  segregating  Europeans  wishing  to  leave 
Secondee.  Sixty-one  Europeans  were  segregated  for  six  days 
in  this  camp  which  was  placed  outside  the  infected  area. 
Altogether  144  separate  buildings  were  fumigated  by  the 
Clayton  apparatus,  or  by  simply  burning  sulphur.  The 
closed  waggons  on  the  railway  were  fumigated  before  loading. 
The  preventive  measures  adopted  are  summarised  as  follows  by 
the  senior  sanitary  officer  :  — 


si 


FIRST  STEPS  343 

(i)  "The  evacuation  of  every  infected  bungalow.  These 
bungalows  were  sealed  up,  and  each  of  them  was 
fumigated  with  sulphur,  and  afterwards  Claytonised. 

(2)  "  The   evacuation    of  the  infected  area,  by  Europeans, 

between  the  hours  of  5  p.m.  and  7  A.M.  This  continued 
for  a  month,  and  no  European  was  infected  after  the 
evacuation  order  was  put  in  force  on  the  evening  of  the 
17th  May.  It  was  a  drastic  measure,  which,  however,  I 
submit  was  justified  by  the  prompt  checking  of  the  out- 
break which  followed  its  enforcement. 

(3)  "  The    fumigation  with    sulphur  gas  of  every  house  in 

business  area  and  of  every  European  bungalow 
outside  it." 

(4)  "  The  perforation  of  all  gutters,  a  hole  being  punched  in 

each  lineal  yard  of  guttering.  It  is  a  matter  of 
common  experience  to  find  a  mosquito-proof  barrel  or 
tank  full  of  mosquitos  on  the  wing,  a  fact  which  is 
explained  by  the  supposition  that  they  lay  their  eggs 
in  the  gutters,  and  that  these  or  their  larvae  are  subse- 
quently washed  down  into  the  tank  or  barrel.  If  the 
tank  or  barrel  be  mosquito-proof,  no  harm  results,  as 
the  mature  insect  is  unable  to  find  an  exit,  but  if  the 
receptacle  is  not  mosquito-proof  it  is  otherwise.  I 
believe  if  this  simple  precaution  were  generally 
adopted,  it  would  be  the  means  of  destroying  the 
potential  breeding-places  of  innumerable  mosquitos." 

(5)  "  Gangs  were  sent  round  collecting  all  tins,  bottles,  or 

other  receptacles  liable  to  breed  mosquitos. 

(6)  "  The  whole  town  was  divided  up  into  mosquito  brigade 

areas,  each  of  which  was  in  charge  of  a  European,  who 
went  round  with  a  small  gang.  At  first  the  people  were 
warned,  and  the  larval  breeding  vessel  was  merely 
oiled  or  upset,  but  afterwards  full  advantage  was  taken 
of  the  special  anti-larval  powers — the  power  to  destroy 
— passed  in  Council  on  the  17th  of  May,  and  any  vessel 
found  to  contain  larvae,  when  no  honest  attempt  had 
been  made  to  screen  it,  was  destroyed.  Barrels  were 
emptied,  turned  over,  and  their  ends  were  staved  in 
with  an  axe.     It  may  be  argued  that  this  is  a  drastic 


344    YELLOW  FEVER  PROPHYLAXIS  IN  WEST  AFRICA 

treatment,  but  it  is  the  only  way.  If  it  is  carried  out, 
people  will  soon  begin  to  take  trouble  and  make  an 
effort  to  keep  their  water  receptacles  free  from  larvae ; 
and  when  they  are  found  to  be  so  doing,  they  should 
be  assisted  by  carpenters  employed  by  the  Govern- 
ment, as  was  afterwards  done  in  Secondee." 

"  I  am  convinced  that  we  shall  never  be  able  in  this 
Colony  to  free  the  Coast  towns  of  Stegomyia,  until  this 
power  to  destroy  larval  breeding  vessels  has  been  con- 
ferred upon  every  medical  officer  and  district  commis- 
sioner in  the  Colony. 

"  I  am  informed  that  such  powers  are  given  in  the 
Togo-country." 

Notices  which  were  issued  by  the  Senior  Sanitary 

Officer 

i.  Notice  upon  importance  of  early  diagnosis,  Secondee,  21st 
May  1 910. — The  following  telegram  was  sent  to  medical 
officers  at  Axim,  Chama,  Tarkwa,  Cape  Coast,  Saltpond, 
Winneba,  Addah,  Quittah,  Akuse,  and  to  the  senior  medical 
officer,  Coomassie  : — 

The  early  diagnosis  of  yellow  fever  is  of  the  utmost 
importance,  and  the  presence  of  albumin  in  the  urine  is  one  of 
the  commonest  symptoms  of  the  disease.  Every  medical 
officer,  therefore,  should  get  ready  a  small  portable  urine 
testing  apparatus,  and  take  it  with  him  whenever  he  is  called 
upon  to  see  a  case  of  illness,  in  order  that  he  may  be  able  to 
test  at  once  for  albumin. 

2.  Precautionary  measures  to  be  taken  in  Gold  Coast  ports. — 
The  following  wires  were  sent  18th  May  1910,  to  the  medical 
officers  at  Chama,  Cape  Coast,  Winneba,  Saltpond,  Quittah, 
Addah  :— 

"  You  should  take  the  following  precautions  to  prevent  an 
outbreak  of  yellow  fever  and  to  meet  such  an  outbreak  : — 

"(1)  Select    sites    for    isolation    hospital  for    Europeans,  a 


FlG.  60.— A  Large  Rain-water  Vat,  forcibly  broken  by  the  Health  Authority 

because  the  owners  failed  to  screen  it,  after  proper  warning. 

Secondee,  1910. 


ITofdcep.  344. 


FIRST  STEPS  345 

contact  camp  for  Europeans,  an  isolation  hospital  for  Natives, 
a  site  for  temporary  housing  of  Europeans  who  may  have  to  be 
evicted  from  an  infected  area. 

"  (2)  Post-mortem  all  suspicious  cases  of  death  among 
Europeans  or  Natives. 

"  (3)  Organise  Mosquito-Brigades  under  European  Super- 
vision. 

"  (4)  Have  all  gutters  perforated,  tanks  made  mosquito 
proof,  and  take  measures  generally  for  the  destruction  of 
mosquitc  larvae." 

A  sum  of  ^500  was  allocated  to  the  above  ports  as  well  as 
to  Secondee  and  Axim  to  take  these  steps  to  prevent  an 
outbreak. 

3.  Public  Notice  upon  the  Danger  of  Breeding  Mosquito  Larva, 
issued  by  the  Sanitary  Board  of  Secondee 

"  This  disease,  yellow  fever,  is  conveyed  by  the  mosquito. 
The  breeding-places  of  these  mosquitos  are  in  any  receptacle  of 
stagnant  water. 

"  The  rule  as  to  the  screening  of  tanks,  water  butts,  etc.,  will 
be  enforced  with  the  utmost  rigour. 

"  Any  person  on  or  near  whose  premises  bottles,  tins,  or  other 
receptacles  that  hold  water,  such  as  imperfect  guttering,  liable 
to  breed  mosquitos  will  be  severely  dealt  with. 

"All  bush  and  weeds  must  be  kept  cleared  around  the 
house." 

On    16th  May  mosquito   brigades  were   organised  and  put 

in  charge  of  competent  officials  and  volunteers  and  apportional 

districts." 

4.  Notice  to  Natives 

Any  Natives  wishing  to  leave  Secondee  should  apply  to  the 
Provincial  Commissioner  for  permission  to  reside  in  the  Native 
Segregation  Camp  beyond  No.  2  Lagoon. 

After  five  days'  isolation  there  they  will  be  given  Medical 
Certificates  and  allowed  to  leave  Secondee. 

The  Camp  will  be  ready  for  occupation  on  Monday,  the  23rd 
of  May. 


346    YELLOW  FEVER  PROPHYLAXIS  IN  WEST  AFRICA 

Notice  sent  2ist  May  1910  to  the  European   Traders  and 
Educated  Natives  in  Secondee 

The  fumes  from  burning  sulphur  kill  mosquitos ;  therefore 
kill  all  the  mosquitos  on  your  premises  by  adopting  the  follow- 
ing procedure,  fumigating  each  room  in  turn  : — 

1.  Measure  the  cubic  capacity  of  the  room. 

2.  Shut  all  the  doors  and  windows  and  paste  paper  or  cloth  over 

every  aperture,  close  the  keyhole  with  paper  or  cloth. 

3.  Take  some   sulphur,   2    lb.   for    every    1000    cub.   ft.   of 

space  in  the  room.  Place  the  sulphur  in  a  tin  and  the 
tin  in  a  basin  containing  water  to  the  depth  of  1  in. 
Pour  a  little  methylated  spirit  over  the  sulphur,  set  fire 
to  it,  and  leave  the  room,  closing  the  door  after  you. 

4.  Keep  the  room  closed  for  three  hours. 

5.  Afterwards  sweep  the  ceiling,  walls,  and  floor  of  the  room, 

and  burn  the  sweepings  to  ensure  the  destruction  of  any 
mosquitos  that  may  be  simply  stupefied. 

6.  Sulphur  may  be  obtained  at  the  Town  Council  Office  any 

morning  from  8  to  9  A.M. 

5.  Notice  sent  by  the  Senior  Sanitary  Officer  to  all  Ministers  of 
Religion  and  Teachers  in  Schools 

The  town  of  Secondee  being  infected  with  yellow  fever  it  is 
at  the  present  time  especially  important  that  the  fact  that  this 
disease  is  solely  caused  by  the  bite  of  a  mosquito  should  be 
impressed  upon  every  member  of  the  native  community,  and  I 
shall  be  grateful  if  you  will  do  your  utmost,  both  in  the  pulpit 
and  out,  to  educate  the  public  in  this  matter.  It  is  especially 
important  also  that  instruction  should  be  given  on  this  subject 
in  all  schools.  You  have  already  been  supplied  with  literature 
giving  the  salient  causes  and  the  methods  of  dealing  with  them. 

6.  Notice  to  Prevent  the  Spread  of   Yellow  Fever  by  the 

Destruction  of  the  Mosquito 

Inside  the  House 

(1)  Keep  all  windows  and  doors  open  to  allow  in  air,  light, 

and  wind  :  three  enemies  of  the  mosquito. 

(2)  Do  not  let  beds  or  other  articles  of  furniture  rest  against 


;.  6i.— A  Substantial  Incinerator.     Coomassie,  Gold  Coast. 


[To  lace  p.  346. 


FIRST  STEPS  347 

the  wall  for  mosquitos  to  lurk  behind.  All  such  articles 
should  be  pulled  out  at  least  18  inches  from  the  wall. 
All  clothes  hanging  in  wardrobes,  or  on  the  wall,  and 
all  books  on  bookshelves  should  be  shaken  freely  every- 
day to  dislodge  mosquitos. 

(3)  Water  in  flower  vases  should  be  changed  daily. 

(4)  The  practice  of  standing  the  legs  of  tables,  cupboards, 

meat-safes,  etc.,  in  tins  of  water  to  prevent  the  ingress 
of  ants  should  be  discontinued. 

(5)  All  vessels  in  the  house,  or  compound,  capable  of 
containing  water  should,  unless  actually  in  use,  be 
turned  upside  down  or  destroyed,  and  those  in  use 
should  be  made  mosquito-proof. 

Outside  the  House 

(6)  All  gutters  should  be  perforated  to  the  extent,  at  least, 
of  one  hole  to  each  lineal  yard  of  guttering. 

(7)  No   depressions   in    the   ground,   ungraded    ditches    or 

other  conditions  likely  to  favour  the  breeding  of 
mosquitos  should  be  permitted  inside  the  compound 
or  in  the  vicinity  of  any  house. 

(8)  All  long  grass,  weeds  and  banana  trees  near  to  houses 

should  be  cut  down. 

In  addition  to  the  preceding  excellent  measure,  which  could 
be  carried  out  without  any  delay,  permanent  reclamation  work 
was  started  by  taking  in  hand  the  filling  up  of  one  of  the 
lagoons  in  Secondee,  where  it  was  shown  Stegoinyia  was  in  the 
habit  of  breeding. 

Owing  to  the  deflection  of  traffic  above  Secondee  to  the 
temporary  Port  of  Chama,  comparatively  little  disturbance  of 
the  shipping  took  place. 

The  senior  sanitary  officer  and  those  who  worked  with  him 
did  not  escape  the  usual  odium  and  criticism  which  is  invariably 
poured  on  those  who  have  the  courage  to  declare  a  port  infected 
with  a  disease  like  yellow  fever.  In  the  end,  however,  as  is  also 
usual,  the  action  of  the  sanitary  staff"  receives  its  full  praise. 


348    YELLOW  FEVER  PROPHYLAXIS  IN  WEST  AFRICA 

Yellow  Fever  Prophylaxis  in  Freetown ,  1910 

The  conditions  obtaining  in  Freetown  differed  from  those  in 
Secondee.  This  port  contains  a  large  population  of  indigenous 
coloured  inhabitants,  a  garrison  high  up  on  one  of  the  hills,  and 
a  very  beautiful  hill  station  at  a  considerable  distance  from 
Freetown,  which  is  the  residential  suburb  for  the  majority  of 
the  white  official  classes.  The  traders  live  in  the  better  class 
houses  in  the  town,  but  comparatively  close  to  native  streets. 
The  smaller  white  traders,  the  Syrians,  live  in  the  midst  of  the 
native  houses,  in  small  poorly  constructed  dwellings.  Both  the 
garrison  and  the  officials  in  the  hill  station  were  very  effectively 
segregated.  The  better  class  traders  lived  in  larger  and 
better  houses,  not  completely  segregated,  however.  The 
Syrians  with  their  families  lived  amongst  and  just  as  the  native 
residents.  The  necessity  for  making  provision  for  the  non- 
immunes was  therefore  not  necessary,  as  this  already  to  a 
large  extent  existed.  Attention  was  therefore  directed  as 
in  Barbados  in  1909  to  bringing  about  a  permanent  anti- 
mosquito  reduction  in  Freetown,  by  increasing  the  visits 
of  inspection,  by  inflicting  fines,  and  by  educating  the 
public  generally.  Indeed  the  method  of  procedure  was  the 
counterpart  of  that  practised  last  year  in  Bridgetown, 
Barbados.  The  course  of  the  outbreak  is  highly  instructive. 
In  the  first  place,  all  those  who  lived  out  of  the  infected 
town  escaped  free.  Those  who  by  the  nature  of  their 
business  were  obliged  to  live  in  the  town  suffered  to  a 
variable  extent;  those  who,  like  the  Syrians,  were  in  the 
worst  part  of  the  town,  in  the  midst  of  the  native  population, 
were  most  heavily  affected.  Thus  the  segregation,  which 
already  existed  in  Freetown,  accomplished  what  the  emergency 
segregation  at  Secondee  and  Bamako  likewise  succeeded  in 
doing.  Yellow  fever  was  declared  15th  May  1910.  Immediately 
a  very  vigorous  anti-5 tegomyia  campaign  was  organised.  The 
following  very  useful  notices  were  issued.     They  may  serve  as 


FIRST  STEPS  349 

guides  in  the  future ;  many  of  them  are  of  local  application,  for 
it  must  always  be  remembered  that  each  country  has  its  own 
special  nuisances : — 

i .  Notice  :  a  Cleaning-up  Day  Appointed 

"  It  is  from  want  of  thought  more  than  from  want  of  energy 
or  effort  that  so  many  old  useless  tins,  bottles,  pans,  calabashes, 
and  other  things  are  not  removed  to  the  refuse  bins  by  occupiers 
from  their  premises,  yards,  and  compounds. 

"  In  order  that  persons  may  be  frequently  reminded  of  their 
duty  in  this  respect,  the  Mayor  and  Councillors  of  this  City  hereby 
declare  and  proclaim  the  day  of  Wednesday  in  each  week  to  be  a 
special  "  Cleaning  -  up  Day,"  and  we  enjoin  all  inhabitants  to 
pay  special  attention  on  that  day  to  ensure  that  all  useless  old 
vessels  are  removed  to  the  refuse  bins,  and  none  allowed  to 
remain  on  their  premises. 

"  It  is  not  intended  that  this  duty  should  be  neglected  on 
other  days ;  but  it  is  hoped  that  when  a  special  reminder  day  is 
observed  every  week,  it  will  assist  the  public  in  preventing 
accumulations  in  their  compounds,  yards,  and  premises  by 
frequently  reminding  them  of  the  duty  of  removal." 

2.  Notice 

The  public  is  hereby  warned  that  Section  4,  Sub-section 
(3)  09  of  "The  Public  Health  Ordinance,  1905"  (No.  15  of 
1905),  reads  as  follows  : — 

"  Where  mosquito  larvae  are  found  in  any  collection  of 
water,  or  in  any  well  or  pool,  channel,  barrel,  tub,  bucket,  or  in 
any  other  vessel,  the  sanitary  authority  may  themselves  abate 
the  same,  and  may  do  what  is  necessary  to  prevent  the  recur- 
rence thereof. 

"  Notice  is  hereby  given  that  in  order  to  prevent  the  recur- 
rence of  mosquito  larvae  in  barrels,  tubs,  etc.,  in  which  mosquito 
larvae  are  found,  measures  will  be  taken  by  the  sanitary 
department,  which  may  include  removal  of  the  vessels,  or  removal 
of  their  bottoms  or  such  portions  of  them  as  will  prevent  the 
recurrence  of  the  above-mentioned  nuisance." 


350    YELLOW  FEVER  PROPHYLAXIS  IN  WEST  AFRICA 

3.  Notice  to  Householders  and  Occupiers 

"  Collect  all  house  and  yard  rubbish,  empty  or  broken  bottles, 
tins,  calabashes,  and  useless  vessels  of  all  kinds,  and  vessels  you 
do  not  require  to  use,  and  place  them  in  a  heap  in  one  place 
in  your  compound  or  yard  near  the  entrance." 

4.  Notice 

"  To  enable  occupiers  of  lots  to  fill  in  pools  and  depressions 
in  the  ground,  the  Government  is  providing  broken  stone  in 
heaps  at  convenient  places  without  any  charge." 

5.  Notice:  Broken  Bottles  on  Boundary   Walls 

"  Break  away  the  glass  till  only  short  sharp  pieces  are  left  in 
the  cement,  then  no  glass  will  be  left  on  the  wall  in  which  water 
can  remain,  and  no  '  wrigglers '  can  live,  and  no  mosquitos 
can  breed  there. 

"Why  not  help  to  stop  quarantine?" 

6.  Notice :  Bottle  Borders 

"  are  not  beautiful,  and  the  deeper  the  hollows  in  the  bottoms 
of  the  bottles  are,  the  more  rain-water  they  hold,  and  the  worse 
they  are,  as  they  breed  mosquitos  from  '  wrigglers '  in  the 
water.  Do  away  with  bottle  borders,  and  place  stones  there 
instead,  and  when  the  '  rains '  are  over,  whitewash  them. 

7.  Notice :   Why  Not  Help  to  Stop  Quarantine  ? 

"  There  are  many  persons  in  Freetown  who  keep  Ojuoro 
Water  in  calabashes,  pots,  etc.,  because  they  think  it  makes  the 
water  good  for  washing  sore  eyes,  but  mosquito  larvae  live  in 
the  water  and  breed  into  mosquitos.  The  same  happens  in 
water  with  kola  leaves  in  it. 

"  A  better  eyewash  can  be  bought  from  any  druggist,  made 
up  of  Boracic  Acid,  \\  drachms  dissolved  in  6  oz.  of  water. 
Anyone  unable  through  poverty  to  pay  druggist  price  can 
obtain  it  for  three  pence  at  the  Colonial  hospital.  This  eye- 
wash will  keep  good  for  a  very  long  time  if  the  bottle  is  corked. 

"  Throw  away  the  Ojuoro  plants  and  water,  and  help  to  get 
rid  of  quarantine  !  " 


MINING  CAMPS  351 

Sulphur  fumigation. — Houses  in  which  cases  of  yellow  fever 
occurred  were  fumigated. 

Health  in  Mining  and  Railway  Construction  Camps 

We  know  from  past  experience,  the  great  loss  in  men  and 
money  which  has  occurred  only  too  often  in  connection  with 
industrial  enterprises  in  the  tropical  world,  and  especially  in 
West  Africa,  ever  since  the  ill-fated  industrial  mission  to 
Bulama. 

It  is  not  unreasonable  to  expect  that  both  private  companies 
and  Governments  should  from  the  outset  make  all  rational 
preparations  to  prevent  disease.  We  know  from  innumerable 
reports  the  success  which  has  attended  engineering  enterprises, 
like  those  at  Panama  and  in  Mexico,  where  sanitary  precautions 
have  been  taken. 

I  have  therefore  thought  it  of  advantage  to  emphasise  those 
precautionary  measures  which,  in  my  experience,  demand 
consideration  at  the  outset  of  every  enterprise  in  a  tropical 
country.  The  measures  group  themselves  under  the  following 
heads : — 

i.  Segregation. — It  must  always  be  remembered  that  the 
white  man  is  in  a  position  of  disadvantage  compared  to  the 
black  man.  We  know  that  the  latter  is  the  host  of  the  virus  of 
malaria,  yellow  fever,  sleeping  sickness,  and  probably  of  other 
diseases,  and  that  to  a  varying  degree  he  is  immune  to  these 
diseases.  On  the  other  hand,  we  know  that  the  white  man  from 
Europe  is  absolutely  non-immune  on  arrival,  and  that  if  any  of 
these  parasites  gain  access  to  his  blood  he  is  incapacitated  from 
work.  Therefore,  knowing  that  the  native  carries  in  his  blood 
stream  the  infecting  virus,  and  that  in  all  probability  the  carrier 
of  the  mosquito  is  at  hand  in  abundance,  it  follows  that  the  first 
thing  to  arrange  for  is  the  segregation  of  the  non-immune. 

The  non-immunes  must  be  provided  for  in  bungalows 
separated  by  at  least,  a  quarter  of  a  mile  from  the  dwelling 
places   of  the   immunes,   i.e.,  the   natives.     This   primary  pre- 


352    YELLOW  FEVER  PROPHYLAXIS  IN  WEST  AFRICA 

caution  should  never  be  omitted.  It  is  an  advance  along  the 
line  of  least  resistance,  and  experience  has  demonstrated  it  is  a 
certain  line  of  defence. 

It  is  only  common  sense  to  protect  the  white  labourer,  who 
must  from  the  outset  be  at  a  certain  disadvantage. 

With  regard  to  the  construction  of  the  bungalows,  there 
are  very  many  exceedingly  good  models.  The  points  to  aim 
at  are  exposure  of  the  bungalow  to  the  prevailing  currents 
of  air ;  the  sleeping  rooms  should  face  the  prevailing  currents. 
For  this  reason  also  elevated  sites,  and  sleeping  rooms  raised 
above  the  ground-level  are  essential.  Mosquitos  shun  currents 
of  air. 

For  the  reasons  above,  all  bush  should  be  cut  close  down  to 
the  ground  ;  nothing  should  impede  the  currents  or  give  shelter 
to  mosquitos. 

In  the  next  place,  the  bungalow  should  be  so  constructed  as 
to  give  the  maximum  shade  and  protection  from  the  sun  rays ; 
for  that  purpose  the  thatch  roof,  in  addition  to  the  iron  roof,  as 
devised  by  Sir  Leslie  Probyn  in  the  Sierra  Leone  Protectorate, 
is  most  useful  and  simple. 

In  order  to  still  further  minimise  the  risk  of  infection,  the 
men  must  be  compelled  to  sleep  under  mosquito  nets,  and, 
where  possible,  part  of  the  verandah  or  a  living  room  should  be 
made  mosquito  proof.  The  chief  factors  which  are  to-day 
reducing  the  sickness  and  mortality  rates  from  malaria  and 
yellow  fever  over  the  tropical  world  are  sleeping  under 
mosquito  nets  and  segregation. 

2.  Mosquito  destruction. — A  defensive  measure  of  easy 
execution  provided  that  it  is  set  about  intelligently,  bearing 
well  in  mind  what  is  to  be  aimed  at.  The  end  desired  is  the 
destruction  of  those  mosquitos  proved  to  be  harmful  to  man, 
and  which  in  consequence,  will  in  every  probability  be  found 
breeding  close  to  him.  In  other  words,  what  should  be  aimed 
at  is  the  extermination  of  those  mosquitos  which  breed  in  and 
immediately  around    the  dwelling-places  of  man.     Were    this 


MINING  VILLAGES  353 

simple  precaution  taken  the  major  proportion  of  the  fevers  of 
West  Africa  would  disappear. 

For  this  purpose  every  article  which  can  by  any  possibility 
hold  water  should  be  removed  from  the  compounds,  roads,  and 
waste  places.  Every  week  a  tour  of  inspection  should  be 
made ;  all  compounds  examined,  and  all  odds  and  ends  removed 
— tin  cans  of  all  kinds  and  discarded  bottles  and  broken  crockery 
are  exceedingly  common  in  all  mining  camps.  Notices  should 
be  pasted  up  warning  the  workmen  of  the  danger  of  leaving  the 
articles  lying  about.  All  these  odds  and  ends  should  be  buried 
in  suitable  places. 

Next  to  the  removal  of  odds  and  ends  should  come 
bush  clearing.  All  compounds,  roads,  and  waste  places  should 
be  kept  absolutely  free  from  weeds  and  bush  of  any  description. 
The  bush  around  every  village  or  camp  should  also  be  kept 
well  down  by  repeated  clearing.  The  bush  obstructs  the 
current  of  air,  facilitates  the  breeding  of  mosquitos,  and 
conceals  all  kind  of  insanitary  material. 

If  there  is  no  pipe-borne  water  supply,  and  cisterns  and 
barrels  have  to  be  used  for  storage  purposes,  these  must  all  be 
securely  screened  by  copper  gauge.  This  can  be  done  at  little 
expense. 

Treatment  of  pools,  marshes,  etc. — If  these  form  in  or 
immediately  around  encampments,  they  will  give  rise  to  the 
breeding  of  dangerous  mosquitos ;  where  possible,  they  should 
be  filled  in ;  but  failing  that,  they  should  be  oiled  once  a  week 
with  kerosene.  None  of  the  precautions  which  I  have  enumerated 
above  are  costly,  nor  require  expensive  administrative  measures 
to  carry  them  out.  They  are  common-sense  methods,  and  an 
intelligent  foreman  could  do  all  that  is  required 

Pure  water  supply. — In  view  of  the  liability  of  all  engineering 
and  mining  camps  to  water-carried  diseases,  care  should  be 
taken  from  the  outset  to  lay  down  a  pure  pipe-borne  water 
supply  where  this  is  possible.  The  greatest  care  must  be  taken 
to  ensure  the  purity  of  the  source.     If  it  is  a  stream  or  spring 

Z 


354    YELLOW  FEVER  PROPHYLAXIS  IN  WEST  AFRICA 

no  house  should  be  allowed  near  it.  Wells  are  a  source  of 
grave  danger  in  any  workman's  camp,  unless  they  are  very 
deep  (artesian) ;  shallow  wells  should  be  rigorously  excluded. 
Until  a  pure  water  supply  is  assured,  directions  should  be 
issued  that  all  water  must  be  boiled  ;  and  boiled  water  should 
be  stored  in  convenient  receptacles  for  the  use  of  the  workmen. 

Disposal  of  excreta. — The  costly  and  disastrous  experience  of 
ankylostomiasis  has  taught  a  salutary  lesson  upon  the  impera- 
tive necessity  of  the  careful  removal  of  night  soil,  and  the 
rigorous  prevention  of  depositing  fsecal  matter  in  the  bush. 
Proper  trenches  should  be  constructed,  and  the  excreta  should 
be  covered  over  so  that  flies  cannot  get  to  them. 

In  connection  with  railway  construction  the  indiscriminate 
formation  of  burrow  pits  should  be  prohibited.  When  on  the 
Gold  Coast,  I  investigated  the  sickness  and  mortality  rate 
amongst  the  men  employed  in  the  construction  of  the  railway 
system,  and  there  is  no  question  that  the  amount  of  sickness 
was  very  high,  and  that  a  great  proportion  of  it  could  have  been 
prevented. 

In  the  mining  centres  also  there  have  been  mysterious  and 
very  fatal  outbreaks  of  what  were  without  doubt  mosquito- 
carried  diseases,  and  in  all  probability  of  the  nature  of  yellow 
fever  and  malaria.  This  could  readily  have  been  avoided  by 
the  use  of  intelligence  and  the  expenditure  of  very  little  money. 

Choice  of  a  medical  officer. — Where,  as  is  usually  the  case, 
mining  and  exploration  companies  employ  their  own  medical 
officers,  I  would  strongly  urge  that  preference  should  be  given 
to  those  candidates  who  possess,  in  addition  to  the  usual 
medical  qualifications,  the  Diplomas  of  Tropical  Medicine  and 
of  Public  Health. 


CHAPTER   XXIV 

QUARANTINE   ADMINISTRATION 

Extracts  from  the  International  Sanitary  Convention  of  American 

Republics 

Signed  October  1905  ;  Ratified  1906  ;  Proclaimed  1909 

Article  1. — Immediate  notification  by  the  government  in 
whose  territory  an  authentic  case  of  yellow  fever  has  occurred 
to  the  other  governments. 

Article  2. — Information  to  be  furnished  to  the  other  govern- 
ments upon  the  yellow  fever  situation,  such  as  place  of  origin, 
number  of  cases,  deaths,  etc.  Distribution  of  Stegomyia  fasciata. 
Prophylactic  measures  taken. 

Article  3. — The  above  information  to  be  directed  to  the 
diplomatic  and  consular  agent  in  the  infected  capital  of  the 
country,  and  to  officials  charged  with  the  public  health  of  the 
several  countries. 

Article  4. — Provides  for  regular  weekly  report  of  progress  of 
the  fever  to  the  various  governments,  including  in  detail  the 
precautions  taken  to  prevent  the  extension  of  disease  : — 

1.  Measures  of  inspection,  isolation,  and  disinfection. 

2.  Measures  taken  to  prevent  the  exportation  of  disease  or 

infected  mosquitos  on  departing  vessels. 

Article  5. — Strongly  recommends  making  it  obligatory  upon 
each  government  to  declare  the  first  case. 

Article  6. — Relates  to  the  organisation  of  a  service  of  direct 
information  between  the  chiefs  of  administration  upon  the 
frontiers. 


356  QUARANTINE  ADMINISTRATION 

Article  7. — Information  of  a  first  case  of  plague,  cholera,  or 
yellow  fever  does  not  justify  against  a  territorial  area  when  it 
may  appear,  the  application  by  other  countries  of  the  prescribed 
measures  of  defence. 

"  Upon  the  occurrence  of  several  non-imported  cases  of 
plague,  or  a  non-imported  case  of  yellow  fever,  or  when  cases  of 
cholera  form  a  focus,  the  area  is  to  be  declared  infected." 

Article  8  limits  the  restrictive  measures  to  the  affected 
region  or  area,  and  defines  what  is  implied  by  "  area."  But  the 
narrowing  down  of  restrictive  measures  to  a  particular  area  in  a 
country  will  depend  upon  the  measures  taken  by  the  govern- 
ment of  the  infected  country  to  confine  the  fever  to  the  particular 
area,  and  provided  also  that  Article  1  has  been  faithfully  com- 
plied with. 

"  When  an  area  is  infected,  no  restrictive  measure  is  taken 
against  departures  from  this  area,  if  these  departures  have 
occurred  five  days,  at  least,  before  the  beginning  of  the 
epidemic." 

Article  9. — That  an  area  should  no  longer  be  considered  as 
infected,  official  proof  must  be  furnished  : — 

1.  That  there  has  been  neither  a  death  or  a  new  case  of 

yellow  fever  for  eighteen  days  after  isolation,  death,  or 
cure  of  the  last  case,  but  each  government  may  reserve 
the  right  to  extend  the  period  ; 

2.  That  measures  against  mosquitos  have  been  executed. 

Note. — "  By  the  isolation  in  the  case  of  yellow  fever 
is  understood  the  isolation  of  the  patient  in  an  apart- 
ment so  screened  as  to  prevent  the  access  of  mosquitos." 

The  following  articles  deal  with  the  defensive  measures 
adopted  by  other  countries  against  an  infected  territory  : — 

Article  10. — The  government  of  each  country  is  obliged  to 
immediately  publish  the  measures  which  it  believes  necessary 
to  take  against  departures  either  from  a  country  or  from  an 
infected  territorial  area. 


PAN-AMERICAN  CONVENTION  357 

Article  II  states  that  there  is  no  merchandise  itself  capable 
of  transmitting  yellow  fever;  it  only  becomes  dangerous  when 
it  harbours  mosquitos. 

Article  12. — No  merchandise  or  objects  shall  be  subjected  to 
disinfection  on  account  of  yellow  fever,  but  the  vehicle  of 
transportation  may  be  subjected  to  fumigation  to  destroy 
mosquitos. 

Article  13  states  that  if  merchandise  is  properly  protected, 
transportation  through  an  infected  territory  should  not  debar  its 
entry  into  the  country  of  destination. 

Article  14. — That  merchandise  should  not  be  prohibited  if  it 
were  shipped  at  least  five  days  before  the  beginning  of  the 
epidemic. 

Article  15  provides  for  the  authority  of  the  country  of 
destination  to  fix  method  and  plan  of  disinfection  for  destruc- 
tion of  mosquitos,  the  disinfection  to  be  carried  out  so  as  to 
cause  the  least  possible  injury  to  merchandise. 

Article  16. — In  case  of  yellow  fever,  postal  parcels  are  not  to 
be  subjected  to  any  restrictions  or  disinfection. 

Articles  17  and  18  relate  to  merchandise  requiring  disinfec- 
tion, more  especially  in  the  case  of  plague. 

Article  19. — Baggage. — There  shall  be  no  disinfection  of 
baggage  on  account  of  yellow  fever. 

Article  20. — Classification  of  ships. — A  ship  is  considered  as 
infected  which  has  plague,  cholera,  or  yellow  fever  on  board,  or 
which  has  presented  one  or  more  cases  of  plague  or  cholera 
within  seven  days,  or  a  case  of  yellow  fever  at  any  time  during 
the  voyage. 

A  ship  is  considered  as  suspected  on  board  of  which  there 
have  been  a  case  or  cases  of  plague  or  cholera  at  the  time  of 
departure  or  during  the  voyage,  but  no  new  case  within  seven 
days ;  also  such  ships  as  have  lain  in  such  proximity  to  the 
infected  shore  as  to  render  them  liable  to  the  access  of 
mosquitos. 

The    ship   is    considered    indemne   which,  although  coming 


358  QUARANTINE  ADMINISTRATION 

from  an  infected  port,  has  had  neither  death  nor  case  of  plague, 
cholera,  or  yellow  fever  on  board,  either  before  departure,  during 
the  voyage,  or  at  the  time  of  arrival,  and  which,  in  the  case  of 
yellow  fever,  has  not  lain  in  such  proximity  to  the  shore  as  to 
render  it  liable,  in  the  opinion  of  the  sanitary  authorities,  to  the 
access  of  mosquitos. 

Article  32. — Ships  coming  from  a  contaminated  port 
which  have  been  disinfected,  and  which  may  have  been  sub- 
jected to  sanitary  measures  applied  in  an  efficient  manner, 
shall  not  undergo  a  second  time  the  same  measure  upon 
their  arrival  at  a  new  port,  provided  that  no  new  case  shall 
have  appeared  since  the  disinfection  was  practised,  and 
that  the  ships  have  not  touched  in  the  meantime  at  an  infected 
port. 

When  a  ship  only  disembarks  passengers  and  their  baggage, 
or  the  mails,  without  having  been  in  communication  with 
terra  firma,  it  is  not  to  be  considered  as  having  touched  at 
a  port,  provided  that  in  the  case  of  yellow  fever  it  has  not 
approached  sufficiently  near  the  shore  to  permit  the  access  of 
mosquitos. 

Article  33. — Passengers  arriving  on  an  infected  ship  have  the 
right  to  demand  of  the  sanitary  authority  of  the  port  a  certifi- 
cate showing  the  date  of  their  arrival,  and  the  measures  to 
which  they  and  their  baggage  have  been  subjected. 

Article  34. — Packet  boats  shall  be  subjected  to  special 
regulations,  to  be  established  by  mutual  agreement  between  the 
countries  interested. 

Article  35. — Without  prejudice  to  the  right  which  govern- 
ments possess  to  agree  upon  the  organisation  of  common 
sanitary  stations,  each  country  should  provide  at  least  one  port 
upon  each  of  its  seaboards,  with  an  organisation  and  equipment 
sufficient  to  receive  a  vessel  whatever  may  be  its  sanitary 
condition. 

When  an  indemne  vessel  coming  from  an  infected  port 
arrives  in  a  large  mercantile  port,  it  is  recommended  that  she 


PAN-AMERICAN  CONVENTION  359 

be  not  sent  to  another  port  for  the  execution  of  the  prescribed 
sanitary  measures. 

In  every  country,  ports  liable  to  the  arrival  of  vessels 
from  ports,  infected  with  plague,  cholera,  or  yellow  fever  should 
be  equipped  in  such  a  manner  that  indemne  vessels  may  there 
undergo  immediately  upon  their  arrival  the  prescribed  measures, 
and  not  be  sent  for  this  purpose  to  another  port. 

Governments  should  make  declaration  of  the  ports  which  are 
open  in  their  territories  to  arrivals  from  ports  infected  with 
plague,  cholera,  or  yellow  fever. 

Article  36. — It  is  recommended  that  in  large  seaports  there 
be  established  : — 

(a)  A  regular  medical  service  and  a  permanent  medical 
supervision  of  the  sanitary  conditions  of  crews  and  the 
inhabitants  of  the  port. 
(J?)  Places  set  apart  for  the  isolation  of  the  sick  and  the 
observation  of  suspected  persons.  In  the  Stegomyia 
belt  there  must  be  a  building  or  part  of  a  building 
screened  against  mosquitos,  and  a  launch  and 
ambulance  similarly  screened. 

(c)  The  necessary  installation  for   efficient  disinfection  and 

bacteriological  laboratories. 

(d)  A  supply  of  potable  water  above  suspicion,  for  the  use  of 

the  port,  and  the  installation  of  a  system  of  sewerage 
and  drainage,  adequate  for  the  removal  of  refuse. 
Article  46. — Ships   infected   with   yellow    fever   are   to   be 
subjected  to  the  following  regulations  : — 

(1)  Medical  visit  (inspection). 

(2)  The  sick  are  to  be  immediately  disembarked,  protected 

by  netting  against  the  access  of  mosquitos,  and  transfer- 
red to  the  place  of  isolation  in  an  ambulance  or  a  litter 
similarly  screened. 

(3)  Other  persons  should  also   be  disembarked    if  possible, 

and  subjected  to  an  observation  of  six  days,  dating  from 
the  day  of  arrival. 


360  QUARANTINE  ADMINISTRATION 

(4)  In  the   place  set   apart  for   observation   there  shall  be 

screened  apartments  or  cages  where  anyone  presenting 
an  elevation  of  temperature  above  37-6°  C.  shall  be 
screened  until  he  may  be  carried  in  the  manner 
indicated  above  to  the  place  of  isolation. 

(5)  The  ship  shall  be  moored  at  least  200  metres  from  the 

inhabited  shore. 

(6)  The   ship   shall   be   fumigated    for    the   destruction    of 

mosquitos  before  the  discharge  of  cargo,  if  possible. 
If  a  fumigation  be  not  possible  before  the  dis- 
charge of  the  cargo,  the  health  authorities  shall  order 
either : — 

(a)  The  employment  of  immune  persons  for  discharging 

the  cargo ;  or 

(b)  If    non-immunes    be    employed    they   shall    be   kept 

under  observation  during  the  discharge  of  cargo 
for  six  days,  to  date  from  the  last  day  of  exposure 
on  board. 

Article  47. — Ships  suspected  of  yellow  fever  are  to  be 
subjected  to  the  measures  which  are  indicated  in  Nos.  1,  3,  and 
5  of  the  preceding  article  ;  and,  if  not  fumigated,  the  cargo  shall 
be  discharged  as  directed  under  the  sub-paragraph  {a)  or  (b) 
of  the  same  article. 

Article  48. — Ships  indemne  from  yellow  fever,  coming  from 
an  infected  port,  after  the  medical  visit  (inspection)  shall  be 
admitted  to  free  pratique,  provided  the  duration  of  the  trip  has 
exceeded  six  days. 

If  the  trip  be  shorter,  the  ship  shall  be  considered  as 
infected. 

Article  49. — All  persons  who  can  prove  their  immunity  to 
yellow  fever  to  the  satisfaction  of  the  health  authorities,  shall  be 
permitted  to  land  at  once. 

Article  50. — It  is  agreed  that  in  the  event  of  a  difference  of 
interpretation  of  the  English  and  Spanish  texts,  the  interpreta- 
tion of  the  English  text  shall  prevail. 


WEST-INDIAN  CONVENTION  361 

West  Indian  Intercolonial  Quarantine  Convention,  1904 

The  following  are  extracts  of  the  Quarantine  Regulations 
adopted  by  the  Convention,  and  which  bear  upon  yellow 
fever  : — 

Infected  place  means  any  place  where  any  infection  or 
contagious  disease  exists  ;  provided  that  the  place  shall  not  be 
regarded  as  an  infected  place  because  of  all  existence  thereat  of 
imported  cases  of  such  disease,  or  because  of  the  occurrence  of  a 
single  non-imported  case. 

Infected  ship  means  a  ship  on  board  of  which  a  case  or 
cases  of  infectious  or  contagious  disease  are  present,  or  have 
occurred  within  a  period  of  seven  days  previous  to  the  date  of 
arrival  of  the  ship,  except  in  the  case  of  smallpox,  when  the 
period  shall  be  twelve  days. 

Suspected  ship  means  a  ship  on  board  of  which  a  case  or 
cases  of  infectious  or  contagious  disease  have  occurred  during 
the  voyage,  or  during  the  stay  of  such  ship  in  the  port  of 
departure,  but  on  board  of  which  no  fresh  case  has  occurred 
within  a  period  of  seven  days  previous  to  the  arrival  of  the  ship, 
except  in  the  case  of  smallpox,  when  such  period  shall  be  twelve 
days. 

Healthy  ship  means  a  ship  which,  although  having  come 
from  an  infected  place,  has  had  on  board  no  deaths  from, 
nor  any  case  of,  infectious  or  contagious  disease,  either  before 
leaving  the  port  of  departure  or  during  the  voyage,  or  on 
arrival. 

Observation  means  isolation  of  passengers,  either  in  a 
proper  station  provided  for  that  purpose  or  on  board  ship,  prior 
to  their  obtaining  free  pratique. 

Surveillance  means  that  passengers  are  not  isolated.  They 
receive  free  pratique  at  once,  and  are  allowed  to  proceed 
to  their  place  of  destination  (the  proper  authority  of  which 
must  be  informed  of  their  arrival),  there  to  undergo  medical 
supervision. 


362  QUARANTINE  ADMINISTRATION 

By  Article  3  a  place  has  ceased  to  be  regarded  as  infected  if 
the  health  officer  is  satisfied  : — 

(a)  That  there  has  been  no  new  case  of  yellow  fever  within 

six  days. 

(b)  That   measures   have   been   taken   with   a  view  to   the 

destruction  in  the  infected  locality  of  mosquitos  on  and 

near  the  infected  premises. 
By  Article  5  infected  ships  shall  be  dealt  with  as  follows : — 
{a)  The  sick  shall,  as  soon  as  possible,  be  removed  from  the 

ship  and  isolated. 

(b)  The  other  persons  on  board  shall  be  permitted  to  land, 

and  be  kept  under  observation,  or  subjected  to 
surveillance. 

(c)  When   observation    is  resorted    to,  the  period  shall   not 

exceed  six  days  in  the  case  of  yellow  fever. 

(d)  When  surveillance  is  resorted  to,  the  period  shall  be  the 

same. 

(e)  In  applying  these  measures,  the  date  of  the  last  case  and 

the  condition  of  the  ship  to  be  taken  into  account. 
{/)  In  the  case  of  yellow  fever,  measures  shall  be  taken  to 

secure  the  destruction  of  mosquitos  and  their  larvae  on 

board. 
By  Article  6  suspected  ships  shall  be  dealt  with  as  follows  : — 

(a)  The  passengers  and  crew  subjected  to  surveillance  during 

a  period  which  shall  not  exceed  six  days  in  the  case  of 
yellow  fever.  The  period  to  date  from  the  arrival  of  the 
ship. 

(b)  That  measures  should  be  taken  to  secure  the  destruction 

of  mosquitos  and  their  larvse  on  board.  When  such 
measures  as  the  health  officer  may  have  deemed 
necessary  in  accordance  with  the  provisions  of  this 
article  have  been  carried  out,  such  ship  shall  immediately 
thereupon  be  admitted  to  free  pratique. 
By  Article  7  healthy  ships  shall  be  admitted  to  free  pratique 
immediately  on  arrival,  irrespective  of  the  nature  of  their  bill  of 


WEST-INDIAN  CONVENTION  363 

health.  They  may,  however,  at  the  discretion  of  the  health 
officer,  be  subjected  to  the  measures  specified  in  paragraph  (/), 
Article  5,  and  the  passengers  and  crew  may  be  subjected  to 
surveillance  during  a  period  of  six  days  in  the  case  of  yellow 
fever.  The  period  of  surveillance  shall  date  from  the  departure 
of  the  ship  from  the  infected  place. 

By  Article  10  a  ship  shall  not  be  regarded  as  having  called  at 
a  place  if  it  has  merely  disembarked  passengers  and  their 
baggage,  or  mails,  without  having  been  in  communication  with 
the  shore. 

Ships  from  an  infected  place  which  have  been  disinfected 
shall  not  again  be  subjected  to  sanitary  measures  on  their 
arrival  in  another  port,  if  in  the  opinion  of  the  health  officer  of 
such  ports  the  measures  applied  were  effective,  unless  a  fresh 
case  of  infectious  or  contagious  disease  has  occurred  on  board 
since  disinfection,  or  unless  they  have  again  called  at  an  infected 
place. 

By  Article  12,  where  measures  of  observation  or  surveillance 
are  prescribed,  the  health  officer  may  exempt  from  their  applica- 
tion any  person  who  is,  in  his  opinion,  immune  to  the  infectious 
or  contagious  disease  on  account  of  which  these  measures  are 
applied. 

By  Article  13,  where  these  regulations  provide  that  a  person 
may  be  permitted  to  proceed  to  his  place  of  destination  subject  to 
surveillance,  the  health  officer,  before  granting  such  permission, 
must  be  satisfied  that  it  is  reasonably  probable  that  the  person 
to  whom  it  is  granted  will  duly  comply  with  the  conditions  of 
surveillance,  and  permission,  if  granted,  shall  be  upon  the 
following  conditions : — 

(a)  He  must  satisfy  the  health  officer  as  to  his  name, 
intended  place  of  destination,  and  his  place  of  residence 
thereat. 

(b)  He  must  agree  fto   present   himself,  and   shall  present 

himself  for  medical  supervision   during  the   prescribed 
period,  and  he  may  be  required  by  the  health  officer  to 


364  QUARANTINE  ADMINISTRATION 

deposit  a  sum  not  exceeding  two  pounds,  which  may  be 
forfeited  if  he  fail  to  present  himself. 

(V)  The  place  must,  in  the  opinion  of  the  health  officer,  be 
conveniently  situated  for  the  medical  supervision. 

If  the  health  officer  is  not  satisfied  as  herein  required,  or  if 
the  person  fails  to  comply  with  paragraphs  (a)  and  (b)  hereof, 
the  health  officer  may  detain  him  under  observation,  or  direct 
him  to  proceed  to  a  specified  place,  and  there  remain  under 
medical  supervision  during  the  prescribed  period. 

In  the  latter  case,  the  provisions  of  paragraph  (p)  hereof  may 
at  the  discretion  of  the  health  officer  be  applied  to  such  person. 

In  the  case  of  a  healthy  ship  the  measure  authorised  by  the 
foregoing  proviso  must  not  be  applied  to  passengers  who  have 
not  embarked  or  gone  ashore  at  the  infected  place,  and  it  should 
not  be  applied  to  those  passengers  who  embarked  or  went 
ashore  at  the  infected  place,  if  circumstances  of  their  stay  there 
afford  reasonable  evidence  of  their  non-infection. 

By  Article  14  merchandise  shall  be  only  disinfected  when  in 
the  opinion  of  the  health  officer  it  is  infected,  provided  that  in 
the  case  of  yellow  fever  merchandise  shall  under  no  circum- 
stances be  liable  to  disinfection  or  prohibition. 

By  Article  16  nothing  in  these  regulations  shall  render  liable 
to  detention,  disinfection,  or  destruction,  any  article,  forming 
part  of  any  mail,  other  than  a  parcel  mail,  conveyed  under  the 
authority  of  the  postal  administration  of  any  government,  or 
shall  prejudicially  affect  the  delivery  in  due  course,  of  any  such 
mail,  other  than  parcel  mail  to  the  post  office. 

By  Article  17  when  any  port  within  the  colonies  is  an  infected 
place,  measures  shall  be  taken  to  prevent  the  embarkation  from 
such  port  of  any  person  showing  any  symptoms  of  infectious  or 
contagious  disease.  To  this  end  every  person  taking  passage 
on  a  ship  leaving  such  port  shall  be  examined  by  the  health 
officer  immediately  before  the  departure  of  the  vessel.  Such 
examination  shall,  as  far  as  practicable,  be  made  by  day  on  the 
shore.     Measures  shall   be  taken  to  prevent  mosquitos,  in  the 


COMPARISONS  365 

case  of  yellow  fever,  from  gaining  access  to  ships.  When  access 
of  mosquitos  to  the  ship  cannot  be  prevented,  measures  should 
be  taken  immediately  before  the  departure  of  the  vessel  to 
secure  the  destruction  of  the  mosquitos  on  board.  The  health 
officer  shall  give  to  the  master  of  the  ship  a  certificate  stating 
in  detail  the  measures  taken. 

By  Article  i8,  when,  in  the  case  of  a  healthy  ship  from  a  port 
which  is  an  infected  place,  the  health  officer  at  the  port  of 
arrival  is  satisfied  that  the  measures  certified  in  Article  17 
have  been  efficiently  carried  out,  such  ship  shall  be  exempted 
from  the  measures  specified  in  Article  7.  Provided  always  that 
if  the  period  specified  in  that  article,  and  dating  from  the 
departure  from  the  infected  place,  shall  not  have  been  complete, 
the  passengers  and  crew  shall  be  subjected  to  surveillance  of 
such  duration  as  is  necessary  to  complete  the  period. 

Comparisons  between  Articles  of  the   West  Indies  and  the 
Pan-American  1905   Sanitary  Congresses 

Both  conventions  agree  that : — 

(1)  A     central     quarantine    authority;     (2)    observation 
stations  (quarantine  stations)  and  isolation  hospitals  ; 
(3)  abolition  of  fees ;  and  (4)  compulsory  notification 
are  essential. 
Definition  of: — 

Infected  place. — Both  conventions  agree  in  regarding  im- 
ported cases  as  not  causing  a  place  to  be  declared  infected, 
Also  that  a  single  first  non-imported  case  does  not  cause  a  place 
to  be  declared  infected  (Article  7,  Pan-American  Convention). 

Infected  ship. — Here  there  is  a  difference  between  the  two 
conventions.  By  the  West-Indian  Conference  the  ship  is 
infected  if  a  case  of  yellow  fever  has  occurred  within  seven 
days  previous  to  date  of  arrival.  In  the  Pan-American  Con- 
vention a  ship  is  infected  if  yellow  fever  has  occurred  at  any 
time  during  the  voyage  (from  last  port).  This  is  no  doubt 
necessary,  as,  if  there  are  mosquitos  on  board,  the  infection  may 


366  QUARANTINE  ADMINISTRATION 

be  transmitted  to  them  from  the  patient,  and  twelve  days  after- 
wards and  onwards  for  a  considerable  time  they  may  be  able 
to  transmit  the  disease. 

Suspected  ship. — This  also  differs.  In  the  case  of  yellow 
fever  the  ship  which  is  regarded  as  suspected  by  the  West-Indian 
Convention  would  be  classed  as  infected  by  the  Pan-American. 
By  the  latter  authority  a  suspected  ship  is  one  on  which, 
although  no  case  of  yellow  fever  has  occurred  at  any  time 
during  the  voyage,  nevertheless  has  lain  in  such  proximity  to 
an  infected  shore  as  to  render  it  liable  to  the  access  of  mosquitos 
{vide  Article  20). 

Healthy  ship. — By  Article  20  of  the  Pan-American  Conven- 
tion, it  is  only  when  a  ship  has  had  no  case  of  yellow  fever 
during  the  voyage,  and  has  not  lain  in  such  proximity  to  the 
shore  as  to  render  it  liable  to  mosquito  infection,  that  it  is 
declared  "  indemne." 

Observation,  surveillance. — Both  conventions  agree  upon  the 
absolute  necessity  of  proper  observation  stations,  and  isolation 
stations.  There  does  not  appear  to  be  anything  in  the  Pan- 
American  Convention  dealing  with  surveillance.  I  think  that 
the  question  of  surveillance  should  be  favourably  considered 
under  certain  circumstances. 

Observation. — The  definition  of  the  term  is  similar  in  both 
conventions. 

When  a  place  ceases  to  be  infected. — Here  there  are  also  sub- 
stantial differences.  By  the  West-Indian  Convention  there 
should  not  have  been  a  new  case  of  yellow  fever  within  six 
days.  By  the  Pan-American  not  until  eighteen  days  after 
isolation,  death,  or  cure.  Both  agree  that  anti-mosquito 
measures  must  have  been  adopted. 

How  infected  ships  are  to  be  treated. — With  regard  to  the 
treatment  of  the  sick,  both  agree  that  they  are  to  be  removed 
at  once.  But  the  Pan-American  Convention  is  very  precise 
upon  how  the  yellow  fever  patients  are  to  be  isolated  and 
removed.     These   very  important   instructions   are  omitted  in 


COMPARISONS  367 

the  West-Indian  Conference.  With  regard  to  the  other 
passengers,  both  conventions  agree  that  the  passengers  should 
land  and  be  kept  under  observation  (in  quarantine)  for  a  period 
of  six  days.  The  Pan-American  Convention  indicates  how  the 
observation  station  is  to  be  protected.  The  West-Indian 
Convention  also  allows  a  period  of  six  days'  surveillance. 

Place  where  the  infected  ship  is  to  be  moored. — The  Pan- 
American  Convention  lays  down  that  ships  must  be  moored 
at  least  200  metres  from  the  inhabited  shore.  In  the  West 
Indian  there  is  no  mention  of  this. 

The  fumigation  of  the  infected  ship. — Both  agree  that  this 
must  be  done. 

Suspected  ships. — As  there  are  differences  in  the  definition  of 
suspected  ships  as  regards  yellow  fever,  in  the  case  of  the  two 
conventions,  strict  comparison  cannot  be  made.  Were,  how- 
ever, the  definition  the  same  in  the  Pan-American  Convention 
the  treatment  would  nearly  coincide  in  the  two  cases,  except 
that  six  days'  surveillance  is  substituted  for  six  days'  observa- 
tion by  the  West-Indian  Conference. 

Healthy  ships. — Here  there  is  a  difference.  By  the  West- 
Indian  Conference  the  ship  is  admitted  to  free  pratique  immedi- 
ately, irrespective  of  the  nature  of  the  bill  of  health,  and 
discretionary  powers  are  given  the  health  officers  to  fumigate 
and  to  exercise  surveillance  of  passengers  and  crew.  By  the 
Pan-American  Convention  the  trip  must  have  exceeded  six 
days,  and  the  ship  must  have  been  medically  inspected  before 
departure. 

Ships  which  have  "called"  at  intermediate  points. — Article  10 
of  the  West-Indian  Conference  and  Article  32  of  the  Pan- 
American  agree  that  vessels  are  not  regarded  as  having  called 
at  a  place  if  they  had  not  been  in  communication  with  the 
shore  (see  Article  32),  and  only  disembarked  passengers,  baggage, 
and  mails. 

No  necessity  for  second  fumigation. — In  the  same  article  there 
is  agreement  about  non-necessity   of  second  fumigation,  pro- 


368  QUARANTINE  ADMINISTRATION 

vided  that  no  new  cases  shall  have  appeared,  or  that  the  first 
fumigation  was  carried  out  efficiently. 

Immunes  to  be  exempted. — The  exceptional  position  of  the 
immune  is  recognised  by  both  conventions ;  compare  Article 
49  (Pan-American),  and  Article  12  (West  Indian). 

Treatment  of  merchandise. — Both  agree  that  merchandise  be 
not  disinfected  :  Article  12  Pan-American  Convention,  and 
Article  14  West-Indian  Convention.  But  in  Article  12  (Pan- 
American)  it  will  be  seen  that  the  vehicle  of  transportation  may 
be  fumigated. 

Mails. — Both  agree  are  not  to  be  fumigated. 

Baggage. — Both  agree  are  not  to  be  fumigated. 

Departure  of  passengers  from  an  infected  area. — There  are 
differences  here  between  the  precautionary  measures  to  be  taken 
according  to  the  two  conventions.  By  the  Pan-American  Con- 
vention no  restrictive  measures  are  to  be  taken  if  the  departures 
have  occurred  at  least  five  days  before  the  commencement  of 
the  epidemic  The  West-Indian  Conference  provides  simply 
for  the  examination  by  the  medical  officer  immediately  before 
the  departure  of  the  vessel. 

Regulations  affecting  passengers  travelling  under  surveillance. — 
There  is  nothing  in  the  articles  of  the  Pan-American  Conference 
dealing  with  permission  being  given  to  travellers  to  proceed  to 
their  destination,  as  is  the  case  with  the  West-Indian  Conference 
in  Article  13. 

Prevention  of  access  of  mosquito  s  to  ship. — In  Article  17  of  the 
West-Indian  Conference  it  is  stated  that  measures  are  to  be 
taken  to  prevent  mosquitos  gaining  access  to  the  ships,  and  if 
this  is  not  possible,  that  measures  "  should  be  taken  "  to  secure 
the  destruction  of  the  mosquitos  on  board  immediately  before 
the  departure  of  the  vessel.  Nothing  is  said  as  regards  proximity 
to  shore — a  point  laid  stress  upon  by  the  Pan-American  Con- 
ference. 

Note. — Cessation  of  infection.  Very  considerable  difficulty 
has  been  found  to  occur  in  practice  over  Article  3   of  the  West- 


REPEATED  PRECAUTIONS  369 

Indian  Convention.  That  is  to  say,  to  determine  when  a  place 
shall  cease  to  be  infected.  I  have  repeatedly  pointed  out  that 
this  will  entirely  depend  upon  the  degree  of  reliance  which  can 
be  placed  upon  the  anti-mosquito  measures  which  the  infected 
country  has  undertaken.  For  as  mosquitos  may  long  remain 
infected,  it  is  obvious  that  only  the  most  careful  fumigation  will 
get  rid  of  any  infected  Stegomyia.  Experience  in  many  places 
in  recent  years  shows  that  isolated  cases  of  yellow  fever 
frequently  appear  months  after  an  outbreak  was  supposed  to 
have  been  stopped. 


2  A 


INDEX 


B 


Acclimatising  fever,  107 
Accra,  remittent  fever,  205 

yellow  fever,  74,  76 
Africa  and  yellow  fever,  95 

West  Coast  of,  yellow  fever  on  the, 
48-95,  140-196 
African  fever,  57 
Agone  and  yellow  fever,  89 
Albertini,  Dr,  233 

Alimentary  tract  and  yellow  fever,  227 

America,   Central,  and   West   Indies, 

symptomatology,     yellow     fever, 

I3I-I39 
references  for  South,  13 
yellow  fever  in  Central,  3-8 
in  South,  9-13 
Anecho  and  yellow  fever,  88 
Animal  experiments  and  yellow  fever, 

224,  225 
Antigua  and  Monserrat,  yellow  fever 

in,  19 
Anti-mosquito  ordinances,  325-333 
Gambia,  328 
Gold  Coast,  328 
prosecutions,  333 
Sierra  Leone,  326 
Southern  Nigeria,  327 
Togoland,  331 
Ascension,  yellow  fever  in,  13,  1 8 
Axim,  pernicious  remittent  fever,  206 
Axim  and  yellow  fever,  73,  195 
remittent  fever,  204 
Sawmills     and     Secondee,     yellow 
fever  cases  at,  181 

371 


Bacillus  icteroides,  224 

Bacillus  of  Sternberg,  224 

Bahamas,  Tortola,  and  Nevis,  yellow 

fever  in,  20 
Bakel,  yellow  fever  in,  66 
Baltimore,  yellow  fever  in,  30 
Bamaku,  yellow  fever  in,  66 
Barbados  and  non-immunes,  149 
cases  seen  in,  134 
yellow  fever  in,  14,  21,  131,  237 
Barcelona,  yellow  fever  history,  34,  36 
Barker,  Dr  G.  L.,  74,  167,  168,  321 
Barry,  Staff-surgeon,  51,  131,  140 
Bathurst,  65 

Beauperthuy  and  Stegomyia,  219 
Belize,  yellow  fever,  240 
Bell,  Staff-surgeon,  69 
Bilious  fever  and  haematemesis,  197 
remittent  fever,  30,  55,  56,  94,  109- 
122,  112,  259,  321 
Cape  Coast,  207 
and  Carroll,  no,  in 
Saltpond,  206 
Birt,  Colonel,  no 
Blackwater  fever   and    yellow    fever, 

203 
Blair,  Surgeon-general,  237 
Blood  counts  and  yellow  fever,  224 
examination  and  yellow  fever,  224 
inoculation   and   yellow  fever,  103- 
105,  222 
Boa  Vista,  55 

and  yellow  fever,  68 
Bonny  and  yellow  fever,  91 


372 


INDEX 


"  Borras,"  109 

Boston,  yellow  fever  in,  32 

Boyle,  J.,  53 

Boyle  and  remittent  fever,  11 2-1 13 

Brazil,  yellow  fever  in,  1 1 

Brest,  yellow  fever  history,  34 

British  Guiana,  references  for  yellow 

fever  in,  1 1 

yellow  fever  in,  9 
Honduras,  yellow  fever  in,  6,  131 

cases  observed  in,  135 

references  for  yellow  fever  in,  6 
Browne,  Dr  S.  O.,  71,  91 
Buenos  Ayres,  yellow  fever  in,  13 
Bulam,  49 
Bulam  fever,  48 
Burnett,  52 
Burrowes,  Dr,  173 

case  yellow  fever  reported  by,  175 
Burton,    Dr    E.     J.,     and    remittent 

fever,  55-112 


Cadiz,  yellow  fever  history,  34 
Calabar  and  yellow  fever,  91 
Callao,  yellow  fever  in,  13 
Cape  Coast,  82,  85,  202,  203 
Cape   Coast,  bilious   remittent  fever, 
207 

1902,  yellow  fever  cases  in,  167, 
169 

remittent  fever,  205 
Cape  Coast  Castle  and  yellow  fever, 

69,  70,  74 
Cape  Verde  Islands  and  yellow  fever, 

68 
Caracas,  yellow  fever  in,  9 
Cargoes  and  passengers'  baggage,  46 
Carroll    and    bilious   remittent  fever, 

no,  III 
Cartagena,  yellow  fever  history,  34,  35 
Carter,  Dr,  221,  242 
Charleston,  yellow  fever  in,  30 
Chichester,  Dr,  164,  228 
Children  and  yellow  fever,  207,  208 


Ciudad  Bolivar,  yellow  fever  in,  9 
Climatorial  bilious  remittent,  112 
Colombia,  yellow  fever  in,  13 
Commissions,  Isthmian  Canal,  8 
Conakry,  yellow  fever  in,  66 
Continued  type  of  yellow  fever,  132, 

133 
Costa  Rica,  yellow  fever  in,  7 

references  for  yellow  fever  in,  7 
"Coup  de  barre,"  128 
Crofts,  Major,  53 
Cuba,  yellow  fever  in,  15,  22,  131 


D 


Dahomey  and  yellow  fever,  89 

Dakar,  yellow  fever  in,  66,  67 

Dandy  or  dengue  fever,  207 

Danish  West  Indies,  yellow  fever,  23 

Davies,  Dr  (Freetown),  57 

Deaths  from  yellow  fever  in  Rio,  1 1 

Dengue  fever,  201,  207 

Descending  type  of  yellow  fever,  132, 

133 
Diagnosis,  difficulties  of,  197 
mistaken,  89,  94 
of  yellow  fever,  197 
Diazo  reaction  and  yellow  fever,  233 
Durham,  H.  E.  (Dr),  43,  138,  220,  228, 

241 
Dutch   Guiana,   reference  for  yellow 
fever  in,  1 1 
yellow  fever  in,  10 


Ecuador,  yellow  fever  in,  13 
Elliot,  Dr  W.  N.,  71,  202 
Elmina,  82,  202 

cases  of  yellow  fever  in,  1895,  71, 
167 

remittent  fever,  204 
Endemial  fever,  107,  108 
Entomology  and  yellow  fever,  265-299 
Epidemiology,  237-251 


INDEX 


373 


Europe,  history  of  yellow  fever  in,  33, 

34 
Experimental  pathology,  219-225 

yellow  fever,  99-106 
Experiments,  inoculation,  221,  222 
Extrinsic  incubation  period,  221 


Febre,  Biliosa,  109 
Fever,  acclimatising,  107 

bilious  remittent,    55,    56,   94,   109- 
122,  207,  259 

Carroll  on,  no,  1 1 1 

and  hsematemesis,  197 
blackwater  and  yellow  fever,  203 
Bulam,  48 
dandy,  207 
dengue,  207 
endemial,  107,  108 
inflammatory,  16,  55,  107,  108 
malignant  bilious  remittent,  122 

malaridl,  202 
remittent,  78,  123-126,  259 

pernicious,  57 
Axim,  206 

Accra,  205 

Axim,  204 

Cape  Coast,  205 

Malta,  no 

Saltpond,  205 

bilious,  Saltpond,  206 

Sierra  Leone,  125 
ships',  42 

simple  bilious,  112,  116 
Fergusson,  Staff-surgeon,  51,  64,  117, 

131 
Fergusson  on  the  symptomatology  of 

the  1837  Freetown  epidemic,  141- 

147 
Fernando  Po  and  yellow  fever,  69 
Findlay,  Dr  C.  J.,  220,  243 
Findlay  and  Stego?nyia,  219,  220 
Findlay  and  yellow  fever  experiments, 

100 
Fomites  and  yellow  fever,  220 


Freetown,  yellow  fever  epidemics  in, 

140,  141-147,  171 
French  Guiana,  yellow  fever  in,  10 


Galveston,  yellow  fever  in,  27,  28 

Gambia,  55 

Garland,  Dr,  82,  83,  84,  86,  165 

Gastric  influenza,  200 

Gibraltar,  yellow  fever  history,  34,  36, 

37 
Gold  Coast,  Medical  Reports,  82 

and   yellow  fever,  69,  70,  71,  72, 
73,  74,  75,  76-85 
Goree,  yellow  fever  in,  66 
Gorgas,    Major,   on     treatment,    212, 

213 
Grand  popo  and  yellow  fever,  89,  90 
Grenada,  yellow  fever  in,  18 
Grubbs,  Dr,  43 
Guadeloupe,  epidemic,  17 
yellow  fever  in,  14,  108 
Gualan,  yellow  fever  in,  6 
Guatemala,     references     for     yellow 

fever  in,  6 
yellow  fever  in,  6 
Guiteras,  Dr  Juan,  132 
Guiteras  and  treatment,  211,  212 


H 


Hasmatemesis  and  bilious  fever,  197 
Harrison,  Professor  (B.  Guiana),  221 
Havelock,  Sir  Arthur,  149,  322 
Hayti  and  St  Domingo,  yellow  fever 

in,  24 
Hepatitis  and  yellow  fever,  207 
Hopkins,  Dr,  92 


I 


Immunity  and  yellow  fever,  251-261 
Incubation,  extrinsic,  221 


374 


INDEX 


Incubation,  intrinsic,  222 
Inflammatory  fever,  16,  55,  107,  108 
Influenza  cases,  199 
Inoculation  experiments,  221,  222 
Isthmian  Canal  Commission,  8 
Ivory  Coast,  yellow  fever  in,  76,  87 


J 


Jamaica,  yellow  fever  in,  14,  20 
Jaundice,  epidemic  or  Weils'  disease, 
201 


K 


Kayes,  yellow  fever  in,  66 
Kenema,  291 
Kennan,  Dr,  62 

notes  of  cases  by,  171 
Key  West,  yellow  fever  in,  27-29 
Kidneys  and  yellow  fever,  229 
King,  Dr  (St  Lucia),  43 
Klein  popo,  88 

Koutonu  and  yellow  fever,  90 
Krueger,  Dr,  88 


Lagos  and  yellow  fever,  92 

La  Guayra,  yellow  fever  in,  9 

Lamprey,  Dr,  59 

Lawson,  Staff-surgeon,  55,  131,  147 

Leghorn,  yellow  fever  history,  34 

Lighters  and  yellow  fever,  46 

Lisbon,  yellow  fever  history,  34 

Liver  and  yellow  fever,  228 

"  Local  bilious  remittent  fever,"  112 

Lome  and  yellow  fever,  89 


Malaria,  197,  201 

and  yellow  fever,  201,  202 
Malignant  bilious  remittent  fever.  122 

malaria,  81,  202 
Majorca,  yellow  fever  history,  34,  36 
Malta  and  remittent  fever,  1 10 

Stegomyia  fasciata  in,  39 
Mantrain  and  yellow  fever,  yj 
Marseilles,  yellow  fever  in,  34 
Martinique,  epidemic  of  yellow  fever, 

17 
and  Guadeloupe,  yellow  fever  in,  23 
yellow  fever  in,  14,  108 

Medical  Report  by  Sir  Arthur  Have- 
lock,  151 

Merida,  yellow  fever  in,  5 

Mesenteric  glands  and  yellow  fever, 
228 

Mexico,  yellow  fever  in,  4 

Micro-parasites  and  yellow  fever,  224 

Microscopical     anatomy     of     yellow 
fever,  231-233 

Mild  cases  of  yellow  fever,  199 
type  of  yellow  fever,  132 

Miners'  camps  and  yellow  fever,  248, 

335,351,353 
Mobile,  yellow  fever  in,  27,  29 
Monserrat  and  Antigua,  yellow  fever 

in,  19 
Monte  Video,  yellow  fever  in,  13 
Morbid  anatomy  of  yellow  fever,  227- 

234 
Mortality  rate  and  yellow  fever,  214, 

215 
Mosquito  destruction,  306 
inoculation   and  yellow  fever,   100- 
102 
Mott,  Dr,  New  Orleans,  221 
Moxley,  Dr,  221 
Murray,  Dr,  87 
Myers,  W.  (Dr),  138,  220,  228 


M 


N 


MacDonald,  Dr,  92 

Malaga,  yellow  fever  history  of,  34,  35 


Nervous  system  and  yellow  fever,  229 
Neumann,  Dr,  224 


INDEX 


375 


Nevis,  Bahamas,  and  Tortola,  yellow 

fever  in,  20 
New  Orleans,  yellow  fever  in,  27,  28, 

131,  239 
New  York,  yellow  fever  in,  31 
Nicaragua,  references  for  yellow  fever 
in,  7 
yellow  fever  in,  7 
Non-immunes  and  Barbados,  149 
North  America,  yellow  fever  in,  25 


O 


Orient  (L'),  yellow  fever  in,  40 
Otto,  Dr,  224 


Prophylaxis,  in  Freetown,  348,  350 
and  fumigation,  313 
and  fumigating  materials,  314 
notification  fear,  316,  318 
oiling,  306 
reclamation,  308 
screening,  306 
in  Secondee,  340,  344,  345 
segregation   of  non-immunes,    304, 

3°5 
in  West  Africa,  340-354 
Puerto  Barrios,  yellow  fever  in,  6 
Puerto  Cortes,  yellow  fever  in,  7 
Puerto  Rico,  yellow  fever  in,  23 
Pym,  Sir  William,  62 


Palma  (Majorca),  yellow  fever  history, 

36 
Panama,  yellow  fever  in,  8 
Parker,  Dr,  91 
Pathology,  experimental,  219-225 

of  yellow  fever,  219-234 
Pensacola,  yellow  fever  in,  27 
Periodicity  and  yellow  fever,  243,  244 
Pernicious  remittent  fever,  57 

Axim,  206 
Philadelphia,  yellow  fever  in,  30 
Port  Limon,  yellow  fever,  7 
Port  Royal,  yellow  fever  in,  21 
Porto  Novo  and  yellow  fever,  90 
Porto  Rico,  1508  epidemic  in,  14 
Progresso,  yellow  fever,  5 
Prophylaxis,  bush  clearing,  310 

canalisation,  308 

Clayton  apparatus,  314 

contacts,  313 

deflection  of  traffic,  312 

and   diagnosis   of  early  cases,  317, 
320 

drainage,  308 

and  early  notification,  313,  316 

education,  310 

fish-stocking,  309 


Quarantine   administration,  311,    355- 
368 
baggage,  357,  368 
in   Central   American    Republics, 

355-36o 
and  ships,  357,  361,  365,  366,  367 
in  West  Indian  Convention,  361, 

364 
Quitta  and  yellow  fever,  71 


R 


Railway  Camps,  335,  351 

carriages  and  yellow  fever,  46 
Ralph,  Dr,  79,  181 
Reed,  Dr  Walter,  221 
Reed,     Walter,     and      experimental 

yellow  fever,  100 
References  for  yellow  fever  in  British 

Guiana,  11 
References  for  yellow  fever  in  British 

Honduras,  6 
References  for  yellow  fever  in  Costa 

Rica,  7 
References  for  yellow  fever  in  Dutch 

Guiana,  1 1 
for  the  Gambia,  65 


376 


INDEX 


References  for  yellow  fever  in  Guate- 
mala, 6 

in  Nicaragua,  7 
in  Panama,  8 
in  Salvador,  8 
on  ships,  46,  47 
for  South  America,  13 
for  yellow  fever   in   Spanish  Hon- 
duras, 7 
for  symptomatology,  131 
Remittent  fever,  78,  123,  124, 125,  126, 

259 
Remittent  fever  and  Dr  E.  J.  Burton, 
112 
Accra,  205 
Axim,  204 
Cape  Coast,  205 
Elmina,  204 
and  Malta,  no 
Saltpond,  205 
and  Sierra  Leone,  125 
and  Southern  Nigeria,  125 
Remitting  type  of  yellow  fever,  132, 

133 
Rice,  Dr,  181,  340,  293 
Rio,  deaths  from  yellow  fever  in,  1 1 
Rome,  Hall  (Dr),  74,  75,  169,  321 


Saint  Bartholomews,  yellow  fever  in, 

23 
Domingo,  yellow  fever  in,  14 
Kitts,  yellow  fever  in,  14 
Lucia,  yellow  fever  in,  14,  18 
Louis,  66 

Martin,  yellow  fever  in,  23 
Nazaire,   yellow  fever    history,   34, 

40,41 
Thomas,  yellow  fever  in,  23 
Vincent,  yellow  fever  in,  18 
Saltpond,  76,  82,  85,  203 
bilious  remittent  fever,  206 
remittent  fever,  205 
yellow  fever  in,  70,  71,  72,  165 


Salvador,  references  for  yellow  fever 
in,  8 
yellow  fever  in,  7 
Sanarelli,  Dr,  224 
San  Pedro,  yellow  fever  in,  7 
Sapele,  92 
Savage,  Dr,  76,  169 
Sawmills,  outbreak    of  yellow  fever, 

1910,  194 
Seasonal  prevalence  and  yellow  fever, 

243-246 
Secondee  and  yellow  fever,  78,   321, 
181 
Axim   and   Sawmills,  yellow   fever 
at,  181 
Segregation,  334-339 
Seidelin,  Dr  Harald,  224,  233 
Senegal,  64 

yellow  fever  in,  65,  67 
Ships'  fever,  42 
Ships,  yellow  fever  on,  references  for, 

46,47 
Sierra  Leone  and  remittent  fever,  125 

yellow  fever,  50 
Simple  bilious  fever,  112,  116 
Slack,  Dr,  79 

Soudan,  yellow  fever  in,  66 
Southampton,  yellow  fever  history,  34 
Southern  Nigeria  and  remittent  fever, 
125 
and  yellow  fever,  90,  91,  92 
Spanish     Honduras,     references     for 
yellow  fever  in,  7 
yellow  fever  in,  6 
Spirochetes  and  yellow  fever,  224 
Spleen  and  yellow  fever,  229 
Stegomyia,  adult,  281 
anti-mosquito  ordinances,  325 
and  baggage,  250 
and  Beauperthuy,  219 
breeding-places,  269-272 
characteristics  of,  273 
and  daylight,  249 
differential  diagnosis  of,  276,  279 
distribution  of,  265 
in  Africa,  267,  287-299 
in  Asia,  268 


INDEX 


377 


Stegomyia,  distribution  of,  in  Australia, 
268 

in  Bonny,  296 

in  Cameroons,  295 

in  Central  America,  268 

in  Dahomey,  294 

in  East  Africa,  297 

in  Europe,  268 

in  Gold  Coast  Colony,  291,  294 

on  Ivory  Coast,  294 

in  Malta,  39 

in  Natal,  297 

in  North  America,  267,  268 

in  Northern  Angola,  297 

in  Nyassaland,  297 

in  Principi,  297 

in  Senegal,  294 

in  Sierra  Leone,  288 

in  Somaliland,  297 

in  Southern  Nigeria,  295 

in  Togoland,  295 

in  West  Indies,  268 
destruction  of,  298 
eggs  of,  279,  280 
and  Findlay,  219,  220 
food  of  larvae,  282 
Kingia  African^  277-279 
larvae,  273,  279,  280 
life  cycle,  280,  284,  285 
and  lighters,  250 
ova,  viability  of,  283 
pupal  stage,  281 
and  railway  carriages,  46,  250 
resistance  of  larvae,  285 
and  ships,  249 
Sugens,  277 
surveys,  272 

Adah,  294 

Accra,  293 

Axim,  293 

Cape  Coast  Castle,  293 
Elmina,  293 
Coomassie,  294 
Lagos,  295,  296 
Obuassi,  294 
Saltpond,  294 
Secondee,  292 


Stegomyia  surveys,  Tarquah,  294 

transport  of,  249 
Sternberg's  bacillus,  224 
Stimson,  Dr,  224 

Swansea,  yellow  fever  history,  34,  40 
Symptomatology  of  the  1837  epidemic, 

141-147 

of  the  1847  outbreak,  147 
of  yellow  fever,  127-165 
of  yellow  fever  in  West  Indies  and 
Central  America,  131,  132,  133, 

134-139 
Syrian,  case  of  yellow  fever  in  a,  160, 
171 


Tampico,  yellow  fever  in,  5 
Tarquah  and  yellow  fever,  77 
Thomas,    H.    Wolferstan    (Dr),    and 

treatment,  209,  225 
Tidlie,  Staff-surgeon,  69 
Togoland  and  yellow  fever,  88 
Tortola,  Nevis,  and  Bahamas,  yellow 

fever  in,  20 
Town  planning,  334 
Trade  routes  and  yellow  fever,  246- 

251 
Transmission,    hereditary,    in    larvae, 

222 
Treatment,    Major    Gorgas    on,   212, 

213 
and  Guiteras,  211,  212 
and  Thomas,  209,  210 
yellow  fever,  208,  213 
Trinidad  and  Tobago,  yellow  fever  in, 

18 
Tweedie,  Dr,  79 


U 


Urinary   reactions   and  yellow  fever, 
233 


378 


INDEX 


V 


Valencia,  yellow  fever  history,  35 
Vascular     system   and  yellow    fever, 

229 
Vera  Cruz,  yellow  fever  in,  4,  5 


W 


Warri,  91 

Weils'  disease  or  epidemic  jaundice, 

201 
West  Indian  soldier,  149 
West   Indies   and    Central    America, 
symptomatology  of  yellow  fever 
in,  131-139 
yellow  fever  references,  17 
yellow  fever  in,  1 5 
Wydah,  92 

and  yellow  fever,  88 


Y 


Yellow  fever  and  acclimatisation,  257 
and  alimentary  tract,  227 
and  animal  experiments,  224,  225 
autopsies  in,  229-231 
benign,  100 

and  the  black  races,  253-256 
and  blackwater  fever,  203 
and  blood-counts,  224 
blood  experiments,  102 
and  blood  examination,  224 
and    blood   inoculation,    103-105, 

222 
campaign  plan  of,  303 
and     cargoes     and     passengers' 

baggage,  46 
and  children,  207,  208 
continued  type  of,  132,  133 
diazo  reaction  in,  233 
diagnosis,  197 
distribution  of — 

in  Accra,  74 

in  Africa,  95 


Yellow  fever,  distribution  of — 

in  Africa,  West  Coast  of,  48,  165 

in  Agone,  89 

in  Anecho,  88 

in  Antigua  and  Monserrat,  18 

in  America,  Central,  3 

in  America,  North,  25 

in  America,  South,  9 

in  Ascension,  13,  68 

in  Axim,  73,  181,  195 

in  Baltimore,  30 

in  Bamaku,  66 

in  Barbados,  21,  131,  237 

in  Boa  Vista,  44,  68 

in  Bonny,  91 

in  Boston,  32 

in  Belize,  240 

in  Buenos  Ayres,  13 

in  Brazil,  n 

in  Cadiz,  34 

in  Calabar,  91 

in  Callao,  13 

in  Cape  Coast  Castle,  69,  70,  74 

in  Cape  Verde  Islands,  68 

in  Caracas,  9 

n  Charleston,  30 

n  Ciudad  Bolivar,  9 

n  Colombia,  13 

n  Costa  Rica,  7 

n  Cuba,  14,  22,  131 

n  Dahomey,  89 

n  Dakar,  66,  67 

n  Ecuador,  13 

n  Elmina,  71 

n  Europe,  33,  34 

n  Freetown,  19 10,  171 

n  Fernando  Po,  69 

n  Galveston,  27,  28 

n  Gambia,  63 

n  Gold  Coast,  69-85 

n  Grand  Popo,  89 

n  Grenada,  18 

n  Guadeloupe,  14,  108 

n  Gualan,  6 

n  Guatemala,  6 

n  La  Guayra,  9 

n  Guiana,  British,  9 


INDEX 


379 


Yellow  fever,  distribution  of— 
in  Guiana,  Dutch,  10 
in  Guiana,  French,  10 
in  Honduras.  British,  6,  131 
in  Honduras,  Spanish,  6 
in  Ivory  Coast,  76,  87 
in  Jamaica,  14,  20 
in  Kayes,  66 
in  Key  West,  29 
in  Koonu,  90 
in  Lome,  89 
in  Mantrain,  yy 
in  Martinique,  108,  141 
in  Martinique  and  Guadeloupe, 


n  Merida,  5 

n  Mexico,  4 

n  Nicaragua,  7 

n  New  Orleans,  27,  28,  131,  239 

n  New  York,  31 

n  L'Orient,  40 

n  Panama,  8 

n  Pensacola,  27,  29 

n  Philadelphia,  30 

n  Port  Limon,  7 

n  Porto  Novo,  90 

n  Porto  Rico,  14 

n  Port  Royal,  21 

n  Progresso,  5 

n  Puerto  Barrios,  6 

n  Puerto  Cortes,  7 

n  Puerto  Rica,  23 

n  Quitta,  71 

n  Rio,  1 1 

n  St  Bartholomews,  23 

n  St  Domingo,  14,  24 

n  St  Kitts  in  1648,  14 

n  St  Lucia  in  1665,  14,  18 

n  St  Martin,  23 

n  St  Nazaire,  40,  41 

n  St  Thomas,  23 

n  St  Vincent,  18 

n  Saltpond,  70,  71,  72 

n  Salvador,  7 

n  San  Pedro,  7 

n  Sawmills,  181 

n  Secondee,  78,  181,  321 


Yellow  fever,  distribution  of — 

in  Senegal,  67 

in  Sierra  Leone,  50 

in  Soudan.  66 

in  Swansea,  40 

in  Tampico,  5 

in  Tarquah,  76 

in  Tobago,  18 

in  Togoland,  88 

in  Trinidad  and  Tobago,  18 

in  Tortola,  Nevis,  and  Bahamas, 
20 

in  Venezuela,  9 

in  Vera  Cruz,  4 

in  West  Indies,  15 

in  Wydah,  88 

in  Zacapa,  6 
descending  type  of,  131,  133 
entomology  of,  265-299 
epidemic,    1837,    symptomatology 

of,  141-147 
experimental,  99-106 
and  fomites,  220 
and  hepatitis,  207 
houses,  241 

and  immunity,  251-261 
kidneys  in,  229 
and  lighters,  46 
liver  in,  228 
lungs  in,  229 
and  malaria,  201,  202 
microscopical  anatomy  of,  231-233 
microparasites,  224 
miners'  camps,  248 
outbreaks,  14,  147 
mesenteric  glands  in,  228 
morbid  anatomy  in,  227-234 
race  mortality  in,  260 
mortality  rate  in,  214,  215 
and  mosquito  inoculation,  100-102 
mild  forms  of,  132,  258 
nervous  system  in,  229 
and  newcomers,  252,  259,  261 
pathology  of,  219-234 
periodicity,  243,  244 
prophylaxis,  303-315 
and  race  susceptibility,  252-261 


380 


INDEX 


Yellow    fever,  references  for  clinical 
history    of   various    epidemics, 

131 

references,  West  Indies,  17 
remitting  type  of,  132,  133 
and  seasonal  prevalence,  243-246 
on  ships,  history  of,  42 
spleen  in,  229 
spirochetes  in,  224 
symptomatology  of,  127-165,  131 
and  trade  routes,  246-251 


Yellow  fever,  treatment,  208-213 
types  of,  99-126 
urinary  reactions,  233 
and  vascular  system,  229 

"  Yellow  Jack,"  42 

Yucatan,  yellow  fever  in,  5 


Zacapa,  yellow  fever  in,  6 


PRINTED   BY   OLIVER   AND    BOYD  ,  EDINBURGH 


>ate-  Due 


MOV  2  4  1945 


.,  ;  . 


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COLUMBIA  UNIVERSITY  LIBRARIES 


0041073037 


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